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) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

39–459 2008

U.S. DEPARTMENT OF VETERANS AFFAIRS 

RESEARCH PROGRAMS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

FIRST SESSION 

OCTOBER 4, 2007 

Serial No. 110–50 

Printed for the use of the Committee on Veterans’ Affairs 

( 


wwoods2 on PRODPC68 with HEARING
ii 

COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

Malcom A. Shorter, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


wwoods2 on PRODPC68 with HEARING
iii 

C O N T E N T S 

October 4, 2007 

Page 

U.S. Department of Veterans Affairs Research Programs ................................... 1 

OPENING STATEMENTS 

Chairman Michael Michaud ................................................................................... 1 

Prepared statement of Chairman Michaud .................................................... 28 

Hon. Jeff Miller, Ranking Republican Member ..................................................... 2 

Prepared statement of Congressman Miller ................................................... 28 

Hon. Henry E. Brown, Jr. ....................................................................................... 13 

WITNESSES 

U.S. Department of Defense, Department of the Army, Major David Rozelle, 

Administrative Officer, Military Advanced Training Center, Walter Reed 

Army Medical Center ........................................................................................... 5 

Prepared statement of Major Rozelle .............................................................. 31 

U.S. Department of Veterans Affairs, Joel Kupersmith, M.D., Chief Research 

and Development Officer, Veterans Health Administration ............................ 24 

Prepared statement of Dr. Kupersmith .......................................................... 55 

Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of Government Relations ..................................................................................................... 14 

Prepared statement of Dr. Zampieri ............................................................... 38 

Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director ..................................................................................................................... 17 

Prepared statement of Ms. Ilem ...................................................................... 48 

Friends of VA Medical Care and Health Research, John R. Feussner, M.D., 

MPH, Professor and Chairman, Department of Medicine, Medical University of South Carolina, Charleston, SC, and Volunteer Staff Physician, 

Ralph H. Johnson Veterans Affairs Medical Center ......................................... 3 

Prepared statement of Dr. Feussner ............................................................... 29 

Pain Care Coalition, Mark J. Lema, M.D, Ph.D, Chair, Department of Anesthesiology, Critical Care and Pain Medicine, Roswell Park Cancer Institute, 

Buffalo, NY, and Professor and Chair, Department of Anesthesiology, University of Buffalo, State University of New York, School of Medicine and 

Biomedical Sciences, and President, American Society of Anesthesiologists .. 7 

Prepared statement of Dr. Lema ..................................................................... 34 

Paralyzed Veterans of America, Carl Blake, National Legislative Director ....... 15 

Prepared statement of Mr. Blake .................................................................... 46 

SUBMISSIONS FOR THE RECORD 

National Association of Veterans’ Research and Education Foundations, statement ...................................................................................................................... 65 

Orthotic and Prosthetic Alliance, statement ......................................................... 67 

Pike, Alvin C., CP, Lead Prosthetist, Minneapolis, MN, Veterans Affairs 

Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs, statement on his own behalf ....................................................... 69 

Salazar, Hon. John T., a Representative in Congress from the State of Colorado, statement .................................................................................................... 70 


wwoods2 on PRODPC68 with HEARING
Page

iv 

MATERIAL SUBMITTED FOR THE RECORD 

Post Hearing Questions and Responses for the Record: 

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Joel Kupersmith, M.D., Chief Research and Development Officer, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated October 11, 2007 ...................................................... 71 

Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, 

Committee on Veterans’ Affairs, to Hon. Gordon Mansfield, Acting Secretary, U.S. Department of Veterans Affairs, letter dated October 5, 2007 ... 76 


wwoods2 on PRODPC68 with HEARING
(1) 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

RESEARCH PROGRAMS 

THURSDAY, OCTOBER 4, 2007 

U. S. HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:02 a.m., in 

Room 334, Cannon House Office Building, Hon. Michael Michaud 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Snyder, Miller, and Brown of 

South Carolina. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. The Subcommittee on Health will come to order. 

I would like to thank everyone for coming here today. 

At this hearing, we will examine the U.S. Department of Veterans Affairs (VA) Research Program. Research is one of the core 

missions of the Veterans Health Administration (VHA). VA is 

unique in that it has the capability to provide clinical services and 

conduct research within the same organization. 

As a result, the VA has done ground-breaking research on topics 

ranging from post traumatic stress disorder (PTSD), prosthetics, 

smoking cessation, and treatment of heart disease. 

The purpose of this hearing is to examine VA research programs, 

particularly in light of the current conflict. As we all know, Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 

have presented us with some new challenges in caring for and 

treating injured soldiers. 

In recent years, we have seen a dramatic increase in the number 

of returning veterans with conditions such as post traumatic stress 

disorder, traumatic brain injury (TBI), and traumatic amputation. 

These conflicts have produced nearly 28,000 severely injured veterans, over 700 of which have had traumatic amputations. 

It is vital that VA continue to push the edge of research in order 

to provide these brave men and women with the most up-to-date 

care available whether they need prosthetics, pain management, 

eye care, or any number of other services. 

It is also important that VA work in collaboration with the U.S. 

Department of Defense (DoD), academic partners, and other public 

and private entities to leverage their resources and knowledge and 

to produce the best possible results out of their research. 

I would like to send a special welcome to one of our witnesses 

today. On June 21, 2003, Major David Rozelle was leading a convoy 


wwoods2 on PRODPC68 with HEARING
2 

west of Baghdad when his vehicle struck a land mine which resulted in the loss of his right foot. 

After spending 8 months recovering at Fort Carson, Colorado, 

Major Rozelle returned to Iraq as a troop commander conducting 

operations in Baghdad and Tel Afar. He was the first troop commander to redeploy in the same battlefield as an amputee in recent 

military history. 

Major Rozelle is currently serving as an Administrative Officer 

at the Military Advanced Training Center (MATC) at Walter Reed 

Army Medical Center. Drawing on his personal and professional 

experience, Major Rozelle helped plan and design this brand new 

facility using the most state-of-the-art research available. 

I would like to welcome you, Major. 

Continuing research is vital to improving healthcare, saving 

lives, and improving the quality of life for our sick and injured. 

I look forward to hearing from our witnesses today about what 

VA is doing and what VA should be doing to advance that core mission, research. 

I would now like to recognize a good colleague and friend, Ranking Member Miller, for an opening statement. 

[The prepared statement of Chairman Michaud appears on 

p. 28.] 

OPENING STATEMENT OF HON. JEFF MILLER 

Mr. MILLER. Thank you very much, Mr. Chairman. 

We all know that research is necessary to generate new knowledge and achieve both scientific and clinical excellence. VA is world 

renowned for its medical research. VA’s Research Program has a 

strong history of success and is credited with pioneering life-saving 

therapies and treatments that have improved healthcare not only 

for veterans, but for patients as a whole. 

This year, for example, the first vaccine for shingles was approved as a result of VA research. 

Modern molecular medicine and rapidly advancing medical technology make a strong research enterprise more important to veterans now more so than ever. 

As we map out the future of VA and the research that they do, 

we must work to ensure that the VA’s goals are aligned with the 

special healthcare needs of both our new generation of veterans 

from the Global War on Terror and our older veterans of previous 

wars. 

Recognizing the value of VA research, we must also be aware 

that nothing is more important than translating research from the 

bench to the bedside. 

I am pleased to see that we will hear from the Administrative 

Officer from the Military Advanced Training Center and have the 

opportunity to discuss collaborative efforts on Federal research for 

the benefit of our military and veterans. 

Mr. Chairman, I appreciate the opportunity to participate in this 

hearing today and yield back the balance of my time. 

[The prepared statement of Congressman Miller appears on 

p. 28.] 

Mr. MICHAUD. I thank the gentleman. 


wwoods2 on PRODPC68 with HEARING
3 

On our first panel today is Dr. John Feussner, who is Professor 

and Chairman of the Department of Medicine, Medical University 

of South Carolina in Charleston, South Carolina. He is testifying 

on behalf of Friends of VA Medical Care and Research (FOVA). 

Major Rozelle, who is the Administrative Officer from the Military Advanced Training Center (MATC) at Walter Reed Army Medical Center. 

And Dr. Mark Lema, who is Chair of the Department of Anesthesiology, who is testifying today on behalf of the Pain Care Coalition 

(PCC). 

So I would like to start off first with Dr. Feussner. 

STATEMENTS JOHN R. FEUSSNER, M.D., MPH, PROFESSOR AND 

CHAIRMAN, DEPARTMENT OF MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, AND VOLUNTEER STAFF PHYSICIAN, RALPH H. JOHNSON VETERANS AFFAIRS MEDICAL CENTER, ON BEHALF OF FRIENDS OF VA 

MEDICAL CARE AND HEALTH RESEARCH; MAJOR DAVID 

ROZELLE, ADMINISTRATIVE OFFICER, MILITARY ADVANCED 

TRAINING CENTER, WALTER REED ARMY MEDICAL CENTER, 

DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE; AND MARK J. LEMA, M.D., PH.D., CHAIR, DEPARTMENT OF ANESTHESIOLOGY, CRITICAL CARE AND PAIN 

MEDICINE, ROSWELL PARK CANCER INSTITUTE, BUFFALO, 

NY, AND PROFESSOR AND CHAIR, DEPARTMENT OF ANESTHESIOLOGY, UNIVERSITY OF BUFFALO, STATE UNIVERSITY 

OF NEW YORK, SCHOOL OF MEDICINE AND BIOMEDICAL 

SCIENCES, AND PRESIDENT, AMERICAN SOCIETY OF ANESTHESIOLOGISTS, ON BEHALF OF PAIN CARE COALITION 

STATEMENT OF JOHN R. FEUSSNER, M.D., MPH 

Dr. FEUSSNER. Good morning, Mr. Chairman, other Members of 

the Committee. My name is John Feussner. 

As you alluded to, I am Professor and Chairman of the Department of Medicine at the Medical University of South Carolina in 

Charleston. I am also a volunteer staff physician at the Ralph 

Johnson VA Medical Center in Charleston. Previously I served VA 

in Washington, D.C., as its Chief Research and Development Officer from 1996 to 2002. 

I would be remiss if I did not thank the Committee straight away 

for its support of VA research as evidenced by your recommendation for a $480 million appropriation for fiscal year 2008. 

As you already stated, VA research is one of the Nation’s premier 

biomedical research programs attracting high caliber clinicians who 

both do research and deliver medical care in VA’s healthcare facilities. These physician researchers represent a scarce national resource and one that VA has sustained over several decades. 

Recall also that the VA Research Program is an intramural program, only supporting physician researchers and other scientists 

who are VA employees. These investigators are at the forefront of 

research that impacts newly returning veterans from Iraq and Afghanistan, especially concerning traumatic blast injuries, burns, 

and post traumatic stress disorder. 


wwoods2 on PRODPC68 with HEARING
4 

And as it has done historically, VA is taking the lead on research 

issues affecting aging veterans who constitute the largest portion 

of veterans seeking treatment in the VA health system. 

The VA research enterprise continues to be veteran centric focusing its resources on illnesses either unique to or highly prevalent 

among veterans. The support and commitment for VA research 

from this Subcommittee really is the good news. However, and there are always many howevers, the current $480 

million appropriation only provides a starting point for a more sustained future investment. New funding is necessary not only to 

sustain current research but to fund new research initiatives, to 

support career development for new physicians and other scientists, and to improve VA’s aging research infrastructure. 

New funding can enhance research in such areas as traumatic 

brain injury, the effects of limb loss from our recent military conflicts and on the physical and psychological well-being of veterans. 

Because of past severe budget constraints, even approved and 

meritorious, VA research projects were either underfunded at a low 

dollar amount or unfunded entirely in part because of the inflationary and other escalating costs of doing high-quality research. 

The FOVA Coalition encourages Congress to consider an orderly 

and predictable growth strategy for the VA research budget for the 

foreseeable future. Otherwise, gains made by this current Congressional appropriation may be lost without adequate attention paid 

to the future year research expenditures. 

However, even with sustained growth, Congress must begin to 

invest in VA’s aging research infrastructure. In 2001, the VA research evaluation project assessed the state of the research infrastructure by surveying sites on the quality of the physical infrastructure, the organizational structure supporting research, and 

the availability of state-of-the-art research equipment. 

We estimated then that a dedicated funding allocation of ap- proximately $40 million per year would be necessary to maintain 

and upgrade VA research facilities. Unfortunately, the events of 

September 11, 2001, intervened and attention to this crucial need 

for VA research waned. 

We all applaud the Committee’s recommendation for a $15 million construction funding stream for VA research facilities in its 

views and estimates for the 2008 fiscal year budget. This is certainly a very, very positive first step. 

However, at least $45 million needs to be allocated for research 

facilities improvement under this minor construction account each 

year for the foreseeable future. Such an annual allocation could improve VA’s research infrastructure in as many as a dozen facilities 

each year. 

Finally, I would like to leave the Committee with several 

thoughts. First, our sincere gratitude for your support of this critical national resource, the VA Research Program. 

Second, please consider a strategic commitment to sustain this 

growth for the foreseeable future so that present gains are simultaneously sustained. 

And, finally, embrace the challenge and commitment to make the 

quality of VA research infrastructure match the quality of VA researchers. We should not expect world-class physicians and sciVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
5 

entists to work in deteriorating research facilities. VA cannot afford 

to lose its best and brightest in this way. 

Again, Mr. Chairman, Members of the Committee, thank you for 

the opportunity to present FOVA’s views on the Research Program. 

I will make every effort to answer your questions. 

[The prepared statement of Dr. Feussner appears on p. 29.] 

Mr. MICHAUD. Thank you very much. 

Major Rozelle. 

STATEMENT OF MAJOR DAVID ROZELLE 

Major ROZELLE. Chairman Michaud and Congressman Miller, 

thank you for inviting me to participate in this hearing alongside 

my colleagues from the Department of Veterans Affairs. 

I am Major David Rozelle, an Armor Officer and Administrative 

Officer of the Military Advanced Training Center or MATC at Walter Reed Medical Center. 

I am excited to talk to you today about the use of advanced technology at the MATC and at the Center for the Intrepid, CFI, at 

Brooke Army Medical Center in San Antonio, Texas. 

The openings of the CFI on the 29th of January 2007, and the 

MATC on September 13th, 2007, demonstrate the tremendous support of American people for our wounded warriors. These facilities 

are symbolic of the significant advances that are being made in the 

care provided to our courageous servicemembers. 

Within the walls of the MATC, one recent patient described it as 

where the magic happens. It is a mix of technology and philosophy 

that allows our warriors to return to a lifetime of the highest physical activity, psychological and emotional function. Each 

servicemember is treated as a tactical athlete bringing the latest 

advances in sports medicine to bear. 

Within the walls of the MATC, there is a multidisciplinary 

health professional team that works together to seamlessly bring 

the patient from recently wounded status to return to warrior status. This team includes representatives from the Veterans Benefits 

Administration, the VA social workers, and VA vocation, education, 

and rehabilitation counselors. 

While the team includes those thought to be part of the traditional rehab team, the physical therapists, occupational therapists, 

physiatrists, and nurse case managers, it also includes psychological liaison providers, biomechanics, the patients, and the patient’s family, among others. 

The facilities boast many state-of-the-art capabilities. These capabilities include the firearms training simulator which includes a 

Blue Tooth technology which replicates the weight, feel, and responsiveness of the actual weapons, an M16, M14, rifles, and the 

nine millimeter pistol. 

Also included is one of the most sophisticated gait labs in the 

world with a 23 camera capture system, a dual force plate treadmill, and six force plates in the floor to analyze gait patterns for 

adjustments to both prosthetics and for treatment plans. 

The best example of both centers’ one-of-a-kind capability would 

be the computer-assisted rehabilitation environment or CAREN 

system. Imagine a helicopter simulator and replace the helicopter 

with a platform placed in front of a virtual reality screen. 


wwoods2 on PRODPC68 with HEARING
6 

Imbedded in this is a treadmill with dual force plates underneath 

the treadmill. 

There are a number of scenarios that patients react to as part 

of the therapy and the future programming capabilities are indeed 

limitless. 

The facility offers a variety of opportunities which include a 

climbing wall, tread wall, an indoor walking and running track 

with a static harness system called the solo step. This support system frees the therapist to watch the patient and to make immediate corrections to their gait and patients the freedom of walking 

on their own. 

The elevating parallel bars were developed specifically for our 

military amputee population. This allows the patients to train for 

community obstacles that they frequently encounter such as sloping streets, sidewalks, or ramps. 

Technology has played a significant role in prosthetic restoration. 

New methods of measurement have resulted in more efficient 

methods of measuring the servicemember’s amputated limb with 

better precision, efficiency, and quality. 

These methods include the computer-aided design, computeraided manufacturing, or CAD CAM, the optical digitizing and 

stereo lithography where CT scans are digitized and used to print 

an accurate three-dimensional model of the residual limb including 

existing heterotrophic ossification. 

The program pioneered and implemented the concept of early 

custom postoperative prostheses and coupled for the first time with 

a policy of utilizing externally powered prostheses components. 

Under this philosophy, the prosthetic sockets are rapidly produced with extremely durable and temporary materials and are 

coupled with the most technologically advanced components. 

The patient receives multiple and frequent sockets to accommodate the volume and shape changes common during the early postoperative phases. 

The use of myoelectric upper prosthetic components instead of 

body powered components places much less stress on the residual 

limb and permits the patient to begin to train much earlier in the 

rehabilitation process. 

The innovative use of current state-of-the-art technology has attracted many manufacturers to our program who are seeking to 

provide new technology to program prior to release to the general 

population. 

The resulting collaboration between the DoD and the Veterans 

Health Administration is ongoing and has already led to several 

significant successful projects. Among these is the development of 

the VA/DoD clinical practice guidelines (CPG) for patient care. The 

CPG sets in place the clinical pathway for both pre- and post-amputation patient care. 

Additionally, partnership between the DoD experts and industry 

recently resulted in the development of the newest generation of 

sea leg, which is a microprocessor controlled prosthetic and even allows instantaneous adjustment to variable walking speeds for amputees. 

As of September 2007, there have been 700 servicemembers who 

have sustained a major limb amputation in support of the Global 


wwoods2 on PRODPC68 with HEARING
7 

War on Terror. Twenty-three percent of these individuals have lost 

an upper limb and over 20 percent have lost more than one limb. 

Nearly 90 percent of these servicemembers have been under the 

age of 35 and as a result, have unique psychosocial needs and generally seek to return to a more active lifestyle than older individuals. 

Additionally, the majority of combat-related amputations do not 

occur in isolation. Over 50 percent have documented traumatic 

brain injury, some with vision and/or hearing loss, and many have 

significant remote fractures and significant soft tissue wounds, others with comorbid paralysis from peripheral nerve injury or central 

cord injury, and nearly all with contaminated wounds requiring 

frequent surgical wash-outs and extensive antibiotic use. 

These complex medical, surgical, and rehabilitative challenges 

require unique approach treatment and warrant dedicated research 

programs to optimize care. 

The advanced training centers have proven to be an ideal setting 

for training and advanced techniques related to amputee care and 

prosthetics. 

In addition to VA/DoD Clinical Rotation Program, we have held 

a number of courses attended by military therapists, Veterans Affairs therapists, and prosthetists from around the country. 

One example of our collaborative efforts was a recent conference 

that brought together internationally recognized experts in amputee care from the DoD, VA, and academia to outline state-of-theart care and set a road map for future research needed for this population. 

The findings of this conference are scheduled to be published in 

a textbook which will be disseminated internationally. 

The combination of advanced technologies, innovative clinical 

practices, caring providers, and an amazing group of warriors in 

transition with strength and courage to seek the high ground and 

continuing to move forward has led to revolutionary changes in our 

understanding of capabilities of individuals with limb loss. 

I thank you for inviting me to talk to you today about the capabilities and the magic at the Military Advanced Training Center at 

Walter Reed and the Center for the Intrepid. 

Your continued support for our wounded, ill, and injured is very 

much appreciated by the soldiers and staff at Walter Reed and 

throughout the Army. 

[The prepared statement of Major Rozelle appears on p. 31.] 

Mr. MICHAUD. Thank you very much, Major. 

Doctor Lema. 

STATEMENT OF MARK J. LEMA, M.D., PH.D. 

Dr. LEMA. Mr. Chairman, Congressman Miller, my name is Dr. 

Mark Lema. I Chair the Department of Anesthesiology, Critical 

Care and Pain Medicine at the University at Buffalo and the 

Roswell Park Cancer Institute. 

Today I represent the Pain Care Coalition, a national advocacy 

effort of the American Academy of Pain Medicine, the American 

Pain Society, the American Headache Society, and the American 

Society of Anesthesiologists or ASA. I currently serve as President 

of the ASA and I am also a pain physician. 


wwoods2 on PRODPC68 with HEARING
8 

Collectively the PCC represents over 50,000 physicians, clinicians, researchers, and educators who serve in leading clinical roles 

in the specialized field of pain management. Some of these specialists work in the VA healthcare systems and others are involved in 

collaborative relationships with research and clinical care programs 

through the VA system. 

Briefly, I would like to discuss the complex problem of pain, especially for the men and women of our military. While we have made 

great advances, much more research needs to be done. 

Mr. Chairman, pain is a very large public health problem in this 

country. Over 80 percent of patients seeking a doctor have pain as 

their primary complaint. The pain problem is even more prevalent 

in our military and veteran populations. 

If miners, movers, and construction workers suffer low back pain 

from heavy lifting, imagine the toll on the spine of those active 

combat duty soldiers in full battle gear. 

If truckers develop back pain from long hauls, imagine the toll 

of those soldiers inside armored vehicles going long distances on 

poor or nonexistent roads. 

If life’s daily stresses serve as triggers for those suffering migraine headaches, imagine the impact of battlefield conditions on 

the military personnel’s stress. 

Over 90 percent of the severely injured veterans enrolled in the 

VA polytrauma centers are suffering from chronic pain with most 

of these veterans having pain at more than one site. Eighty-five 

percent have traumatic brain injury. 

As professionals in the pain care field, we must ensure that the 

brave military men and women who serve or have served our country get the very best care in pain management possible. However, 

many of these injuries have no cure. 

I applaud the VA for its leadership in focusing resources on the 

assessment and treatment of pain. We are particularly supportive 

of the national pain management strategy initiated in November 

1998. There is still much work to be done. 

The Pain Care Coalition believes VA’s pain research effort can 

and must be significantly enhanced. We urge this Subcommittee to 

develop targeted legislation with three basic components. 

First, Congress should require VA to establish a focused research 

and training program directed at both acute and chronic pain within its medical and prosthetic research programs at VA headquarters. 

Second, Congress should authorize, and VA should designate, cooperative centers throughout the country for research and education on pain. 

Third, Congress should authorize these newly created pain research centers to compete on an equal basis with other priority research areas. 

Mr. Chairman and Members of this Subcommittee, pain is often 

characterized as the invisible disease. Unlike cancer, diabetes, and 

heart disease, there are no reliable tests to confirm the presence 

and severity of pain. But that is no excuse for letting research efforts lag behind those of other VA research priorities. 

In closing, I would like to quote U.S. Army Deputy Surgeon General, Joseph G. Webb, Jr. In October 2005, he said, ‘‘Wounded solVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
9 

diers in Iraq and Afghanistan benefit from receiving some of the 

most advanced technologies and techniques in medicine today. The 

benefits of advanced pain management are improved postoperative 

outcomes and the potential to eliminate chronic pain, particularly 

in amputees.’’ 

Mr. Chairman and Members of this Subcommittee, please help 

ensure adequate funding for pain management research. We must 

join together so that our brave men and women returning from 

combat continue to receive the best care possible by developing 

cures for traumatic, painful conditions. 

Thank you. I would be glad to answer any questions. 

[The prepared statement of Dr. Lema appears on p. 34.] 

Mr. MICHAUD. Thank you very much. And we thank the other 

two panelists also. 

A couple of questions. Major, my first question will be to you. 

You have played a very large role in the design process at MATC. 

Could you give us a brief description of how the MATC was designed with the wounded warrior in mind and what are the lessons 

that we and VA might be able to learn from that process? 

Major ROZELLE. Well, I think the key, Mr. Chairman, was that 

we got together the entire team, so we looked at this center and 

who was going to be in it first. And then we went to those agencies. 

Rather than letting engineers design it for us, we brought a team 

together to say what do we need. 

We were then able to sit down and review through a number of 

different sets and see what space we needed and what was required based on what the Health Facility and Planning Agency 

would allow us to have space-wise. And we continued to reconfigure 

it in the process. 

Another successful approach we used with the Military Advanced 

Training Center was we did what is called a design build. Basically 

we were able to sit down as a team with the engineers that were 

designing it for us as they did their 10, 30, 50, 75, and 90 percent 

drawings and continue to make adjustments based off our teamwork where we would get together and virtually walk through the 

building and continue to do business. 

We actually continued to make changes in design to include 

walls and room space and room function up until the 90 percent. 

It was a very successful tool rather than walking into a building 

that was designed by someone else and then having to occupy and 

then make changes. 

There were two systems that we actually had to build the building around. One is the gait lab that I talked about specifically because it required an isolated slab. That is something you cannot 

post engineer into a building. The second, of course, would be the 

computer-assisted rehab environment, the CAREN, which is the 

simulation room. It is another isolated slab and literally had to 

have the building built around it. 

And to answer your second question, how can we move forward 

on this, we continue to get our teams together to look at the future 

of the Walter Reed at Bethesda, for instance. Everything from our 

building will be moved from MATC to Bethesda. That is a very 

unique characteristic. 


wwoods2 on PRODPC68 with HEARING
10 

And then, of course, when it is at Bethesda, we will be able to 

test it and it will be tested and we can make changes as we move 

forward. 

We would like to think that our building is the model that people 

already have come to study on what does this advanced facility 

look like and are very proud of it. 

Mr. MICHAUD. Thank you very much. That was very helpful. 

Dr. Feussner, as you know, there are going to be several new VA 

hospitals built over the next few years. As the VA moves forward 

with these new hospitals, what type of infrastructure would you 

like them to consider incorporating into these facilities in order to 

support research activities? 

Dr. FEUSSNER. Well, with new hospitals, we are beyond the point 

of any remodeling issues. So new hospitals should be built with 

new research facilities. 

I think you know, you were in the building in Charleston, the 

Strom Thurmond Medical Research Building in Charleston, which 

was a joint venture between the Federal Government, State government in South Carolina, and the Medical University, it is stateof-the-art research facility, about 120,000 square feet. 

The kind of collaboration and integration of research disciplines 

that the Major has referred to occur commonly in these state-ofthe-art facilities. And the price back when our facility was built in 

1996, the price was about $45 million. It is probably substantially 

more than that, but also substantially less than building a brand 

new hospital facility. It would be unfortunate if the building of hospitals, if it did not occur simultaneously with the build-out of new 

research facilities. 

Mr. MICHAUD. Thank you. 

Another question for the Major. You have worked hard when you 

look at the collaboration with VA on patient care. Can you go in 

a little more detail about the collaboration between DoD and VA 

in your facilities in terms of patient care, resources, and research? 

Major ROZELLE. Well, Mr. Chairman, specifically to integrating 

the VA into our building, now we for the first time have all three 

offices represented within our building. The idea is that this seamless transition should occur at the building. And we are very proud 

to have them there inside our walls. And that is a large step forward from where we were when I was injured in 2003. 

As far as collaborative research, it seems that we at least quarterly have either training or conference where we bring together 

our partners which we consider VA to be one and, of course, academia another where we reach out and bring people together 

whether it is something simple as, you know, say, a running clinic 

where we bring in whether it is VA prosthetists or therapists in to 

observe this young special population on these very unique prostheses or whether it is a conference where we are getting together 

to write textbooks. 

And we continue to look at the future of, you know, specifically 

gait analysis and the future protocols that will come out of that 

room are endless as well as the CAREN system, you know, another 

great collaborative opportunity for DoD and VA to work together. 

Mr. MICHAUD. Thank you very much. 


wwoods2 on PRODPC68 with HEARING
11 

My last question is for Dr. Lema. You talked about amputees’ experience with phantom limb and stump pains. Can you be more 

specific as to what these pains are and do you think part of it is 

because of where the joints are for these limbs? Is that part of the 

reason—we just really have not done enough research in that particular area? 

Dr. LEMA. Thank you, Mr. Chairman. 

Phantom limb pain is a very complex pain problem because it is 

a central pain problem. The brain is actually wired to understand 

that it has fingers regardless of whether fingers develop. And, likewise, when an organ such as an arm or a leg is removed, the body 

still has imprinted in the brain the capability of sensing the nerve 

fibers that would have gone to that area but were avulsed during 

the trauma. 

So that is how pain can often be recognized by a person who no 

longer has a limb. And oftentimes a person will remember the last 

thing before the nerve has been destroyed. So many times, it is a 

painful avulsion and that could be the last thing that our military 

personnel remember. 

So there are number of different phantom limb pains, three in 

particular. One is through chronic disease which is actually different than phantom limb pain from traumatic avulsion. In other 

words, losing a limb as a result of a blast. 

And, finally, there is also stump pain and stump pain oftentimes 

can be a result of poor surgical technique in a controlled environment or the inability to actually approximate avulsed tissue because of the blast. And that puts stress and strain on the blood vessels and the nerves as the surgeons try and approximate the skin 

around the stump. And, of course, anytime pressure is placed on 

the prosthetic device, intense pain can be experienced by the patient. 

So we are talking about all of those. But in particular, we are 

talking about coordinating pain management into these areas to 

the point where you recognize that pain management is a discreet 

entity. 

Currently if you look at all of the programs that the VA has and 

you envision each one of those programs as a pebble in a bowl, pain 

medicine is the water that touches all of those pebbles. We would 

like to make it a discreet entity so that it does not lose its focus 

when the other research efforts are being focused, as the Major 

said, on very important advances in prosthetic therapy. 

Mr. MICHAUD. Great. Thank you very much. 

Mr. Miller. 

Mr. MILLER. Continuing with the pain issue, in the research that 

VA is doing now with returning veterans from OEF/OIF, is that research that can be utilized with older veterans? Or are some of 

these issues more directly related to new wounds or issues that we 

are seeing in the battlefield today? 

Dr. LEMA. Your best chance of success is usually addressing pain 

aggressively at the first opportunity. Oftentimes effectively treating 

acute pain will prevent the changes that actually go on. These are 

changes that actually occur in nerve cell remodeling. In other 

words, the nerves change their personalities. And oftentimes, once 

that happens, it is more difficult to treat. 


wwoods2 on PRODPC68 with HEARING
12 

So people who have actually had chronic pain that is more longstanding have to actually undergo different types of treatment that 

is oftentimes more difficult. 

We have an opportunity with this war to address the transition 

between the effectiveness of what we see in our military hospitals 

to then what we see for our veterans around the country. We believe that that transition is not as seamless as it could be and especially in the area of pain medicine where 90 percent have 

unrelieved pain. It is incapacitating. 

Imagine if you had a headache right now, you could not focus on 

this hearing. But imagine if that headache persisted every day of 

your life. How would you be able to function as a normal human 

being? And that is what we are trying to address. 

Mr. MILLER. Major, when the MATC was being designed and 

built, was cost an issue or were you hopefully provided an opportunity to put in there what you needed? 

Major ROZELLE. Well, the cost is always a consideration, Congressman. But, you know, we had guidelines for the building. You 

know, we had $10 million to spend on the facility. But I never felt 

limited. I never felt strapped by that amount. If I needed something, I knew that I could go back and request it. So thank you for 

that. 

But also, you know, we had great support within the Department 

of Defense as well. We had lots of visitors who came and said what 

else can we put into the facility. And after a tour, they realized 

that we pretty much had put everything in there that we needed. 

So we would never turn down money certainly, but we had 

enough for the mission and we actually ended up coming in under 

budget. So we are very proud of that. The $10 million was the right 

amount for that facility. 

Mr. MILLER. You may have already addressed this in your testimony, but as far as replicating the MATC around the country, is 

it being done? Where is it being done? Others obviously are looking 

to what you are doing; what does the future hold? 

Major ROZELLE. Well, sir, you know, I think that we have had 

a lot of visitors from around the world. You know, we looked to our 

partners in this war. We had the Canadians come take a look at 

what we are doing. The Israelis are interested in what we are 

doing. 

The Colombians have also come and taken a close look at, you 

know, treating our soldiers together, you know, the idea that we 

have clinically proven that, you know, if you have a peer group, 

people heal better together. And, you know, that is something that 

is unique to what we are doing. You know, when you are newly injured and you spread those units across the country, they are finding themselves healing by themselves. 

So this package that we have created is certainly exportable, but 

we also do not want to say we should build a Center of Excellence 

or ten more Centers of Excellence across the country. We are satisfied with what we have now. 

Mr. MILLER. That is all, Mr. Chairman. 

Mr. MICHAUD. Mr. Brown. 


wwoods2 on PRODPC68 with HEARING
13 

OPENING STATEMENT OF HON. HENRY E. BROWN, JR. 

Mr. BROWN OF SOUTH CAROLINA. Thank you, Mr. Chairman. And 

I am sorry I was late. I had to be in a markup in another Committee. 

But it is a real pleasure to welcome my good friend from Charleston, Dr. Feussner, and we are grateful for his involvement in 

healthcare delivery not only just in the private sector in Charleston 

but also in the VA community. 

And, of course, you know we have been working with you, Mr. 

Chairman, and other Members of the Committee to try to explore 

some areas of possibility that we might be able to share some of 

the research and some of the expertise that we find between the 

VA and the Medical University. 

And we are grateful that you would come. You know, we have 

been on the cutting edge, I guess, of the Strom Thurmond Gazes, 

you know, Heart Research Center. And as we do, I guess, an expansion program there at the Medical University that, you know, 

it gives us more opportunity to combine some of our resources between the VA and the Medical University. 

So we are grateful to have you here today. I am sorry I missed 

your testimony, but I am sorry I missed the testimony of the rest 

of you gentlemen, too. But, anyway, thank you. 

It is a concerted effort that we are trying to combine as many 

of the resources of the taxpayers’ dollars to not have duplications 

but to find the best of both worlds and combine those, you know, 

intellectual capitals to try to be sure that our young men and 

women that are coming back from harm’s way in terrible physical 

condition, that their needs will be met. 

And I think it is absolutely a great idea that when those guys 

come back, they need the, I guess, support of their group. And so 

I think being in a group kind of a setting gives a little more of, I 

think, encouragement in their healing process. 

But it has been a real pleasure, Mr. Chairman, to serve on this 

Committee to try to find and meet the needs of our veterans. And 

we are grateful for the Charleston model as we try to not only save 

the taxpayers money but to bring the best, brightest minds together to be sure that we have a broad front to attack the needs 

of our veterans. 

And thank you, John, for being here. 

Dr. FEUSSNER. Thank you, Congressman Brown. 

Mr. MICHAUD. Thank you once again. I would like to thank the 

panel for your outstanding testimony this morning and look forward to working with you. 

And it goes without saying, Major, we really appreciate all that 

you have given to this great Nation of ours. We are all extremely 

proud of you and the other men and women who proudly wear the 

uniform of the United States. So thank you very much. 

Major ROZELLE. It is an honor. Thank you. 

Mr. MICHAUD. This panel is dismissed, and we will set up for our 

second panel. 

I would like to welcome the second panel here: Dr. Tom 

Zampieri, who is the Director of Government Relations for the 

Blinded Veterans Association (BVA); Carl Blake, who is the National Legislative Director for the Paralyzed Veterans of America 


wwoods2 on PRODPC68 with HEARING
14 

(PVA); and Joy Ilem, who is the Assistant National Legislative Director for the Disabled American Veterans (DAV). 

I would like to thank all three of you for joining us today. And 

we will start with Dr. Zampieri and work down. Thank you. 

STATEMENTS OF THOMAS ZAMPIERI, PH.D., DIRECTOR OF 

GOVERNMENT RELATIONS, BLINDED VETERANS ASSOCIATION; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 

PARALYZED VETERANS OF AMERICA; AND JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED 

AMERICAN VETERANS 

STATEMENT OF THOMAS ZAMPIERI, PH.D. 

Mr. ZAMPIERI. Chairman Michaud and Ranking Member Miller 

and Members of the House Veterans’ Affairs Subcommittee on 

Health, on behalf of the Blinded Veterans Association, we thank 

you for this opportunity to present our testimony today on important research programs. 

BVA is the only Congressionally chartered veteran service organization exclusively dedicated to serving the needs of our Nation’s 

blinded veterans and their families. And we have worked for over 

62 years with the VA closely in developing special rehabilitative 

programs, both outpatient and inpatient rehabilitative programs 

for our Nation’s blinded veterans. 

Our testimony includes a great deal of data and statistics that 

hopefully will not overwhelm anybody, but I thought it was important that people understand that the prevalence and the incidence 

of blindness and low vision in the United States is one out of every 

28 Americans over the age of 40, which amounts to 3.3 million 

Americans are either blind or have low vision. 

This figure is from 2004 and when broken down, it separates to 

2.3 million with low vision and about a million who are legally 

blind. However, each year, 200,000 more Americans develop age-related macular degeneration, which is the most common cause of 

blindness in our older veterans over age 65. Diabetic retinopathy 

is another frequent cause of blindness in younger veterans between 

the ages of 40 and 65. 

The take-away from some of this is that the employment rate of 

those individuals of working age between age 19 and age 65 who 

have a vision-related disability remains still only at half of the nondisabled workforce, 38 percent, and that figure is at the end of a 

lot of the other employment data that I put in there. 

And I think that is a statement on the importance of research 

in regards to not only medical research but advanced prosthetic devices and new technologies to assist individuals in their recovery 

from vision loss and being able to enter the workforce. 

The economic and social impacts of this is just tremendous, $68 

billion annually. One figure I read was there are currently over 

400,000 older Americans who are in nursing homes strictly because 

of blindness, which is costing Medicare $11 billion a year for those 

individuals to be in nursing homes. And a lot of those could function independently if they were able to have rehabilitation. 

One of the most common causes of individuals being admitted to 

nursing homes is actually falls. 


wwoods2 on PRODPC68 with HEARING
15 

The other thing is that as of September 25th, 2007, this number 

constantly changes, there have been 27,767 servicemembers 

wounded in Iraq and Afghanistan. The number of men and women 

requiring air and medical evacuation from Iraq between March 

19th, 2003, and September 17th, 2007, was 8,298 of which 1,162 

or 13 percent had sustained combat eye trauma. Thirteen percent 

of all those wounded evacuated from OIF and OEF have sustained 

serious combat eye wounds. 

This is the highest percentage of eye wounded evacuated in any 

war in 100 years. This is a staggering number and, in fact, the previous witness who testified about pain being the silent aspect of the 

injuries, Bob Woodruff from ABC News who attended our convention said that eye injuries apparently is the silent epidemic of war 

casualties in the sense that these numbers, you never hear about 

them. 

And I am alarmed. And even in our previous testimonies, we 

found, you know, difficulty in getting any accurate numbers. 

The other aspect of this is the traumatic brain injuries which are 

associated with a large percentage of vision-related complications. 

Of the 3,900 TBI patients, it is estimated that 80 percent of those 

complain of visual-related symptoms. And at the polytrauma centers, 62 percent of the patients are diagnosed as having a TBI-related diagnosis with dysfunction of diplopia, convergence disorders, 

photophobia, ocular motor dysfunction, inability to read. 

We are proud of the fact that the VA has devoted a lot of new 

resources into expansion of low vision outpatient services and the 

support that this Committee has given that effort. We are also 

pleased that one of their research projects is on retinal research up 

in Boston on development of an artificial retinal implant. 

But what concerns us is that the amount of funding that is dedicated toward both DoD and VA vision research, we feel, is far too 

low. 

I would be happy to answer questions about all that. We appreciate the ability to present our testimony today. 

The one thing that would help us tremendously, we feel, is passage of H.R. 3558 which was introduced by a couple Members of 

this Committee. The ‘‘Military Eye Trauma Treatment Act of 2007’’ 

would create a Military Eye Trauma Center of Excellence and eye 

trauma registry. 

And this is vital, we feel, because until there is an accurate accounting of these eye casualties and this information is shared with 

the VA, then what we hope will come out of this is new best practices like they are doing with prosthetics and new research geared 

toward the experiences that the DoD ophthalmologists and the VA 

ophthalmologists are now having to cope with. 

And so, again, I appreciate this opportunity to present our testimony and look forward to your questions. 

[The prepared statement of Dr. Zampieri appears on p. 38.] 

Mr. MICHAUD. Mr. Blake. 

STATEMENT OF CARL BLAKE 

Mr. BLAKE. Mr. Chairman, Mr. Miller, and Mr. Brown, on behalf 

of PVA, I would like to thank you for the opportunity to testify 

today on the research programs administered by the VA. 


wwoods2 on PRODPC68 with HEARING
16 

As you know, research is a vital part of veterans’ healthcare and 

an essential mission for our National healthcare system. 

In testimony during the 109th Congress, PVA supported legislation that would create Amputation and Prosthetic Rehabilitation 

Centers of Excellence similar to those that are done for Multiple 

Sclerosis and for Parkinson’s Disease. The need for these centers 

is amplified by the number of veterans of OIF and OEF who have 

amputations. 

We believe these centers could partner with the new Military Advanced Training Center that was just spoken about in some detail 

that recently opened at Walter Reed. This partnership could enhance the long-term provision of these services to veterans as it 

would allow the VA to remain on the cutting edge of amputation 

and prosthetic research in conjunction with DoD. 

This is particularly important as the VA will likely be responsible for caring for these men and women throughout the course of 

their lives. 

Additionally, VHA should be required to partner with manufacturers, dealers, payers, and advocates to develop performance test 

standards for amputee and prosthetic devices. 

An example of these types of test standards is the American National Standards Institute, ANSI, and Rehabilitation Engineering 

and Assistive Technology Society of North America, REATSNA, 

wheelchair performance standards. These standards are a collaborative effort with specific impacts on wheelchair research and development, consumer disclosure, and payer decisions. 

PVA believes that these centers could be the spearhead for development of evidence-based performance test standards for amputee 

and prosthetic devices within the VA. 

PVA also has a particular interest in research projects that the 

VA administers as it continues to address neurotrauma and sensory loss primarily as a result of spinal cord injury or disease or 

traumatic brain injury. 

As you are well aware, TBI is recognized as the signature injury 

of combat in Iraq and Afghanistan. According to the VA’s estimates, TBI and various degrees of spinal cord injury account for 

nearly 25 percent of the combat casualties sustained by servicemembers in OIF and OEF. 

Despite the positive gains by advancements in body armor, the 

head as well as the cervical spine are exposed to significantly more 

trauma. This has not only led to specific injuries related to TBI and 

paralysis, but also vision loss, psychological problems, and the larger polytrauma aspect. As such, it is absolutely essential that continued research in the areas of TBI and SCI continue to advance. 

Likewise, PVA believes more research must be conducted to 

evaluate symptoms and treatment methods of veterans who have 

experienced TBI. This is essential to allow VA to deal with both the 

medical and mental health aspects of TBI including research into 

the long-term consequences of mild TBI in OEF/OIF veterans. 

Furthermore, TBI symptoms and treatments can be better assessed for previous generations of veterans who have experienced 

similar injuries. 

PVA is particularly interested in the VA’s special research 

project that focuses on genomic medicine. The thrust of this project 


wwoods2 on PRODPC68 with HEARING
17 

is to link veterans’ genetic information with the VA electronic 

health record. The program will ultimately allow clinicians to make 

better decisions for veterans based on their genetic information. 

Furthermore, it will address patients’ rights, informed consent, 

privacy, and ownership of genetic material involved with genetic 

tissue banking. 

However, despite the expectations of this exciting field, we must 

reiterate that additional new funding will be necessary. Genomic 

medicine cannot be advanced by simply reshuffling funding priorities within existing VHA research and development funding. If it 

is placed into a stream where it will compete with current VA 

projects, the sheer scope and cost of genomic medicine alone will 

overrun all other ongoing projects. 

Finally I must emphasize our concern about funding for the overall Medical and Prosthetic Research Program. We certainly appreciate the fact that the appropriations bills passed by the House and 

Senate meet or exceed the $480 million recommended by the Independent Budget for fiscal year 2008 and we appreciate this Committee’s support for those measures. 

However, with the outcome of the appropriations still hanging in 

limbo and the fact that no appropriation has been provided even 

as the start of the new fiscal year has already passed, we remain 

concerned about the ongoing viability of the VA Research Program. 

Mr. Chairman and Members of the Subcommittee, again I would 

like to thank you for the opportunity to testify and I would be 

happy to answer any questions that you might have. 

[The prepared statement of Mr. Blake appears on p. 46.] 

Mr. MICHAUD. Thank you very much, Mr. Blake. 

Ms. Ilem. 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you, Mr. Chairman and Members of the Subcommittee, for inviting the Disabled American Veterans to provide 

testimony on VA research programs. 

There are a number of research areas we believe warrant special 

attention including prosthetics, traumatic brain injury, mental 

health, women veterans, the aging veteran population, Gulf War, 

and minority veterans. 

A significant number of young servicemembers are returning 

from Iraq and Afghanistan with complex polytraumatic injuries. 

VA will be responsible for the health maintenance of this population for decades. Therefore, it is essential that VA remains the 

leader in advancing new technologies in prosthetic and orthotic 

items while refining rehabilitation models and promoting good 

health outcomes for veterans with amputations and other trauma. 

Traumatic brain injury or TBI is another area of particular concern for DAV. While severe brain injuries are more easily recognized, some servicemembers exposed to explosive blasts have no obvious or visible injury. It is believed that many OEF/OIF veterans 

have suffered mild brain injuries or concussions that have gone undetected. 

Emerging literature strongly suggests that even mild TBI injuries may have long-term mental health consequences. With the influx of servicemembers returning with mild or moderate TBI, reVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
18 

search should be expanded on the evaluation and treatment of this 

injury in new veterans. However, studies undertaken by VA should 

also include older veterans of past military conflicts who have suffered similar injuries that were undetected, undiagnosed, or 

misdiagnosed and untreated. 

Combat-related mental health readjustment issues should also be 

a critical research priority for VA. Veterans of these current wars 

have a wide range of possible mental health conditions such as readjustment disorder, anxiety, depression, PTSD, and substance 

abuse. 

Early studies suggest that substance abuse is a growing problem 

in a large number of returning war veterans. Therefore, we urge 

VA to continue research into this critical area as well and to identify the best treatment strategies to address substance abuse and 

associated mental health and readjustment issues while continuing 

to address the needs of older veterans with these problems. 

We urge Congress to remain vigilant to ensure that mental 

health research and appropriate treatment programs are authorized and sufficiently funded. 

With increasing numbers of women serving in the military today 

and with more women veterans seeking VA healthcare following 

military service, VA must be prepared to meet their unique physical and mental health needs. Women’s health research is essential 

to fully understand the healthcare needs of this population and to 

develop high-quality services and treatments. 

While many of the health problems of male and female veterans 

returning from combat operations will be similar, VA must address 

the health issues that pose special challenges for women. 

DAV has recommended that VA focus its women health research 

on finding the healthcare delivery model that demonstrates the 

best clinical outcomes for women veterans, assesses the barriers 

that women perceive or have experienced in seeking VA healthcare 

services, conduct a long-term health study of women who served in 

combat theaters, and conduct research to fully understand the dual 

burden of military sexual trauma and combat-related PTSD. 

While additional research and resources must be provided to better treat our newest generation of combat veterans, VA still has a 

large number of aging veterans. In that respect, research focused 

on diabetes, hypertension, heart disease, dementia, and other 

chronic illnesses affecting older populations must continue. 

Likewise, additional research is needed to explore and develop 

systematic methods for efficacious treatments for Gulf War veterans with unexplained medical symptoms and illnesses so that a 

collection of best practices becomes available to all VA clinicians in 

the field. 

A June 2007 VA study found that racial and ethnic disparities 

appear to exist in all clinical areas. Researchers noted that this 

finding was especially troubling since it may indicate that disparities in healthcare delivery contribute to disparities in health outcomes. It is clear from this study that VA needs to continue this 

important research and find solutions to this problem. 

From its earliest days, biomedical rehabilitation and health services research has been an integral part of VA’s overall mission. 

Today the VA system offers veterans the best care anywhere as 


wwoods2 on PRODPC68 with HEARING
19 

confirmed by numerous health industry experts. But millions of 

sick and disabled veterans depend on the VA healthcare system to 

help them overcome severely disabling injuries. 

We urge VA to press forward and to remain on the cutting edge 

of healthcare through its esteemed research program and we encourage this Subcommittee to maintain necessary oversight of VA 

research programs and to provide sufficient funding to help VA improve service and health outcomes for disabled veterans. 

Mr. Chairman, that concludes my testimony and I will be happy 

to answer any questions you may have. Thank you. 

[The prepared statement of Ms. Ilem appears on p. 48.] 

Mr. MICHAUD. Thank you very much. And I thank the other two 

panelists as well. 

Everyone on this panel agrees that VA should continue to put 

money and resources into research and development, although 

money is limited, so we have to sometimes make priorities. 

I would like to ask all three of you what should the VA’s top 

three priorities be as they relate to research and development? We 

will start with Dr. Zampieri. 

Mr. ZAMPIERI. I think that from our perspective, you know, one 

of the unique aspects of the war and the injured coming back is 

that when you look at all the different types of research, you are 

not going to find in the private sector a thousand severe, you know, 

eye trauma cases. 

I mean, you talk to private university ophthalmologists who do 

emergency room work and you look at national eye registry data, 

you know, like three percent of all Americans who go in the emergency rooms suffer from a severe type of industrial eye injury. 

And, you know, we feel that there are certain types of military 

injuries that should be a priority as far as whether it is amputation, prosthetics research, vision research, spinal cord injury (SCI), 

you know, speaking for my friends here, because you cannot just 

go out in the private sector and find those dollars. 

I mean, you know, these are unprecedented. One of our attachments shows you pictures of what we are talking about. And, you 

know, I was upset that in the Congressionally directed DoD research, there is $4.9 million for eye research. And I am saying to 

myself, you know, is something wrong with this picture in regards 

to—you know, there are certain things that we have a responsibility for and I just think that anything related to combat trauma, 

the Blinded Veterans Association thinks should be a priority. 

The other aspect of this is one of the difficulties is technology. 

Everybody is overwhelmed. The good news is there are lots of new 

adaptive technology equipment that is out there and sorting 

through those and testing those and finding out which ones really 

work the best is actually overwhelming for some of the staff that 

I talk to. 

So it is a good news, bad news story. You have so much emphasis 

nowadays on technology research, but, you know, how do you sort 

that out within the VA and Department of Defense as to which 

really work well? And if you are going to invest money into those, 

is your return going to be, you know, valuable? 

Anyway, thank you. 


wwoods2 on PRODPC68 with HEARING
20 

Mr. BLAKE. Well, Mr. Chairman, I would say first that I do not 

think that is a fair question because the scope of research programs conducted by the VA is so broad that I do not know that we 

could pinpoint certain ones. 

As an advocate for Paralyzed Veterans of America, I do not think 

I would be doing my job if I did not say that we believe 

neurosensory loss and trauma associated with spinal cord injuries 

should be at the top of the list, but I think that falls into a broader 

category in some fashion. 

Like Tom mentioned about combat-related traumas and injury, I 

do not think that you can tailor research to that because there are 

so many avenues under that whether it be TBI, psychological disorders and research associated with that, those sorts of things. But 

I think there is probably a broader field associated with it. 

I believe that the genomic medicine research is going to be a 

growing field. It is a massive scope in that program, but I think 

a lot of focus is going to be placed there because of the potential 

for it. But outside of that, I do not know that I could give you one, 

two, or three items that would be the way to go. 

Ms. ILEM. I think I would have to concur with my colleagues that 

it is a difficult question to try to pinpoint if you had to pick the 

top three. And I think probably VA is grappling with that as well. 

They have, you know, a limited amount of funding and they have 

to choose the areas that they feel are the most critical. And I would 

assume they are looking at issues that they think they are going 

to have the largest problem in those populations. 

And obviously they want to, I am sure, remain on the cutting 

edge with prosthetic technology that is coming out and make sure 

that this small group, relatively small group maintains, you know, 

to continue to have these really incredible prosthetic items available to them throughout their lifetime. 

And the traumatic brain injury, obviously everyone is very concerned about it in the mild and moderate category, not just the 

most severe, and what are the long-term consequences for that population. 

And I think mental health too. Everybody is very concerned 

about that because of the long-term chronic consequences that can 

lead to a lot of other issues. 

So it is a difficult question, but I think that we all agree that 

anything related to military service, VA should have the funding 

available to do the research necessary to make sure that the appropriate programs and services are available and the best treatments 

in the world for these veterans. 

Mr. MICHAUD. Well, you all did a very good job answering the 

question and part of it, I expected your answer to be what it was. 

So I appreciate it. 

I will give you an easy one to answer. What ideas do you have 

on how VA and DoD and other government agencies can improve 

on how to conduct research in a collaborative manner? What works 

best? 

Mr. BLAKE. What works best? 

Mr. MICHAUD. Yes. I mean, can VA and DoD and other agencies 

do a better job on collaborative research and development? 


wwoods2 on PRODPC68 with HEARING
21 

Mr. BLAKE. Well, I would say the key is to ensure that as we 

move forward, at least particularly with the newest generation of 

veterans, that DoD and the VA do not operate their own programs 

within a vacuum. That is not saying that they do. The VA does an 

outstanding job of working with academic affiliates, the private sector, and within the VA. The DoD has done some degree of research, 

particularly with the newest related casualties from Iraq and Afghanistan and it is important to ensure that some kind of link is 

established in all of these areas. 

I think the prosthetics issue is going to be a big issue because 

a lot of the men and women out at Walter Reed, Bethesda, and certain other locations are getting the most advanced prosthetics and 

it is important to ensure that the VA is tied in to what is going 

on there so that they understand this ever-evolving technology because they will be the ones in the long term responsible for meeting 

the needs of these men and women. 

Ms. ILEM. Yeah. I would agree with that. And I think that VA 

and DoD, you know, we hear about some of these collaborative 

projects and things that they are working on. And it is great to 

hear that VA is being allowed to, you know, bring their prosthetists 

and other folks out there, you know. 

But I think we would like to see more of that right from the getgo in terms of, you know, they are both interested in what is happening with this population and it crosses over. And, you know, 

however they can work together to make sure that all of these 

treatments and best practices are both developed in both, you 

know, agencies as a collaborative effort, I think, is in the best interest of our veterans. 

Mr. MICHAUD. Great. Thank you. 

Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. 

Let the record reflect I will not ask the panel a difficult question 

that they cannot answer. It is very unfair of you to do that. 

One question because our time is running short, I know we have 

a vote coming up shortly. One thing that we find in the Federal 

bureaucracy is that there are many agencies doing duplicative 

work, research. There is such a competition for research dollars. 

Do you feel, and this could go to any or all of you, and TBI a 

perfect example, that there should be a single Federal clearinghouse agency for medical research? Would that aid in what we are 

trying to accomplish, providing the best care to those who need it? 

Mr. BLAKE. Well, that is not an easy one either. 

Ms. ILEM. I know. That is not easy either. 

Mr. MILLER. I did not say it was easy. 

Mr. ZAMPIERI. That is sort of like, you know, can we reform the 

Tax Code. 

Mr. MILLER. Yes, we can. 

Mr. ZAMPIERI. You know, I guess you could, but it is not going 

to be easy. Speaking as a person who is a clinical provider as a 

physician assistant for 25 years, you know, the universe of Federal 

research and university research and private foundations is complex. 

And I guess, you know, my way of approaching this is that, 

again, that, you know, I think that DoD and VA should look at a 


wwoods2 on PRODPC68 with HEARING
22 

way to partner even more on the specific research again with these 

different types of injuries and stuff from the war. 

And, you know, like I mentioned, one of the things that we would 

like to see is whether it is associated with this Eye Center of Excellence, but a joint technology sort of research center, you know, 

where they work together on all this, you know, advanced technology development, similar to what they are doing now in regards 

to amputee prosthetics, you know, and just build on that. 

I think the problem once you get off into the world of the National Institutes of Health (NIH) and all that is the complexities 

of the competitive research that goes on outside. I do not think one 

‘‘Federal research czar’’ could handle this. 

Mr. BLAKE. I think it is certainly an idea worth consideration. I 

think the problem that you run into is although the vast majority 

of research programs benefit a broad cross-section of the general 

population maybe in different ways, one type of research does not 

necessarily benefit the other type of group. 

And we would certainly hate to see any kind of a national management of research where a program is managed that does not 

benefit veterans in some fashion. That is not to say that even research conducted with the VA benefits all of a society, but we believe it does. But we need to ensure that the VA has that directed 

expertise as it relates to the issues surrounding veterans and their 

own experiences. 

So I am not sure that a single agency could manage research in 

that fashion and ensure that it is universally applicable and would 

benefit everyone. 

I would say that NIH maybe on some level does a little bit of 

that now because a lot of research in some fashion passes through 

the doors of NIH before it comes back out to wherever it goes. Even 

the VA has its own partnerships in most cases with research 

through NIH. 

Ms. ILEM. I mean, I would not have much more to add than I 

think what both my colleagues have said other than, you know, I 

think it is an idea worth exploring or looking at. However, I think 

I would need more time to really think about that and the implications. 

And the thing that first came to mind was thinking about, you 

know, making sure not just about the duplication but make sure 

there is not stunting of creativity and thoughts and ideas and different avenues of approaching things. 

But certainly it is something that we could, you know, further 

explore and get back to you or your staff with. 

Mr. MILLER. That is it. 

Mr. MICHAUD. Mr. Brown. 

Mr. BROWN OF SOUTH CAROLINA. Mr. Chairman, I am going to 

be pretty easy on the panel. I have a yes or no answer. 

I know down in Charleston, I think we mentioned with the other 

panel that we do have, you know, combined with heart, with the 

Strom Thurmond Gazes Research, you know, Clinic. 

And so I would ask the question if you do not think in order to 

be able to utilize the best taxpayers’ dollars is to combine some 

kind of oversight to all of these agencies and also include in the 


wwoods2 on PRODPC68 with HEARING
23 

private sector because I think there is a lot of duplication of effort 

out there and I know competition is always good for the funds. 

But would you agree that by including the private sector that 

that gives us another dimension of intellectual capital that we 

probably would not have just within our own bounds? 

Mr. ZAMPIERI. I would agree that, you know, that there is obviously, so I do not get misquoted, I think that there should be effective coordinated private-sector research, you know, from the VA 

perspective. 

You know, a lot of the physicians that I worked with, for example, in Houston, Texas, at the VA Medical Center, we did a lot of 

prostate cancer research in association with Baylor University. 

And, in fact, most of the VA urologists would have said that we 

would not have been able to do some of that research without the 

support of the, you know, outside universities. 

And so, you know, my background gives me that, you know, that 

this is very important. I guess, you know, my concern, though, is 

that there is again sometimes specific military and VA types of research that it would be difficult to find that type of private university research going on. 

While I do know that there is a lot of retinal research going on 

in private university driven programs and retinal implants and 

optic nerve and things like that, so there is a relationship there 

that they could draw upon. 

Mr. BROWN OF SOUTH CAROLINA. I was just hoping that you 

would just say yes and we would not have to reinvent the wheel. 

And I know a lot of times, there is a lot of research being focused 

on, you know, the same issue in many different areas. And if they 

could combine those resources, it seems like it would be better utilization of our taxpayers’ dollars. 

And I know that buzzer just went off and that means that we 

are going to have to go vote pretty shortly, so I will just leave the 

other two panelists an option to say yes or no. 

Mr. BLAKE. How about maybe? 

Ms. ILEM. Same. 

Mr. BROWN OF SOUTH CAROLINA. Thank you very much. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you. 

And, Dr. Snyder. 

Mr. SNYDER. Thank you, Mr. Chairman. I will not ask any questions because we have votes going on. 

But I appreciate your all’s advocacy on funding for medical research and proper funding and the detail in your written statements that you go on about what that means for the folks that are 

members of your organizations. I think your advocacy is absolutely 

vital and I appreciate your doing it year after year. Thank you. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. I would like to thank this panel. 

And I do not know if we can fit the third panel in within the next 

5 minutes. The third panel is Dr. Joel Kupersmith, who is an M.D. 

He is the Chief Research and Development Officer from the VHA. 

He is accompanied by Dr. Tim O’Leary and Dr. Michael Selzer. 

I would like to thank you very much, Dr. Kupersmith, and look 

forward to hearing your testimony. 


wwoods2 on PRODPC68 with HEARING
24 

STATEMENT OF JOEL KUPERSMITH, M.D., CHIEF RESEARCH 

AND DEVELOPMENT OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY TIMOTHY O’LEARY, M.D., PH.D., DIRECTOR, 

BIOMEDICAL LABORATORY AND CLINICAL SCIENCE RESEARCH AND DEVELOPMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 

MICHAEL E. SELZER, M.D., PH.D., DIRECTOR, REHABILITATION RESEARCH AND DEVELOPMENT, VETERANS HEALTH 

ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. KUPERSMITH. Thank you very much, Mr. Chairman. 

Mr. Chairman and Members of the Subcommittee, thank you for 

the opportunity to discuss the Department of Veterans Affairs Medical and Prosthetic Research Program. 

With me are Dr. Timothy O’Leary, Director of Biomedical Laboratory and Clinical Science Research, and Dr. Michael Selzer, Director of Rehabilitation Research and Development. 

For more than 80 years, VA research has been a valuable investment with remarkable and lasting returns. The history of VA research is filled with examples of how it has improved care including developing numerous advances in prosthetics, developing a system that allows tetraplegics’ brain waves to turn on lights and 

open e-mails, pioneering, understanding, and treatment of post 

traumatic stress disorder or PTSD, identifying genes associated 

with Alzheimer’s disease, premature aging, schizophrenia, and diabetes. 

In recognition of their innovative work, VA researchers have received three Nobel Prizes and six Lasker Awards. 

VA research is an intramural program where clinical care and 

research occur under one roof. This unique advantage allows VA 

investigators to bring scientific discovery from the laboratory bench 

to the patient’s bedside making this program a most effective tool 

to improve veterans’ care. 

All our veterans from those who served in World War II to those 

returning from current conflicts in Iraq and Afghanistan deserve 

the very best care possible. Therefore, VA has a comprehensive research agenda using all the tools of modern science to develop new 

treatments for physical injuries, illnesses, and mental health disorders, to improve access to healthcare, and to address long-term 

needs. 

A priority area for VA research is health issues of veterans of 

Operation Iraq and Enduring Freedom or OIF/OEF such as prosthetics healthcare, pain, traumatic brain injury, spinal cord injury, 

sensory loss, mental health, and polytrauma. 

Let me provide a few examples of exciting research in these 

areas. VA researchers are developing improved materials and designs for prostheses. One project under way involves building a 

new flexible prosthetic wrist to allow upper arm amputees to interact with objects in a more life-like fashion and with fewer mechanical failures. 

In addition, VA recently unveiled a computer-driven ankle foot 

prostheses that helps restore amputees’ ability to walk normally. In 

a preliminary study of the prototype, patients used less energy durVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
25 

ing walking, had fewer balance problems, and walked 15 percent 

faster. 

To learn more about combat-related mental health, VA researchers are collaborating with DoD to collect risk factors and health information from military personnel prior to the deployments to Iraq. 

These soldiers will be reassessed upon their return and several 

times afterward to identify changes that occurred following combat 

duty and to identify risk factors for PTSD and other health conditions. 

An additional goal is to examine whether and how PTSD and 

traumatic brain injury are related. 

Excruciating pain is experienced by more than 50 percent of patients after spinal cord injury. VA investigators have identified a 

particular mechanism responsible for conveying pain signals to the 

brain and are now using that discovery to develop a new pain 

treatment. This research has the potential to benefit the general 

public as well as veterans. 

Other priority research areas include treating and preventing 

chronic diseases such as diabetes, obesity, HIV/AIDS, and heart 

disease, understanding healthcare needs and service utilization of 

women veterans, treating conditions including substance abuse, adjustment and anxiety disorders, psychotic disorders, dementia and 

memory disorders, and related brain damage and providing personalized medicine. 

VA is at the forefront of developing treatment that is tailored 

specifically to an individual based on genetic medicine also known 

as personalized medicine. It will increase the effectiveness and 

safety of healthcare, drug treatments, and disease prevention efforts. Personalized medicine is considered the direction for 

healthcare in the 21st century. 

VA research supports a broad initiative examining access to 

healthcare aimed at identifying system-wide gaps in care, assessing 

specific access issues and barriers for special populations, assessing 

the impact of new programs, practice structures, and organizations, 

and developing and evaluating quality improvement efforts, organizational and management interventions, implementation initiatives, and new technologies. 

Further, meeting the long-term care needs of the aging veteran 

population continues to be a high priority for VA research. A major 

focus is on research that will enhance care coordination to improve 

quality of life for long-term care patients. 

Other projects include those aimed at caregivers and a new initiative focused on developing approaches to community-based longterm care. 

In conclusion, VA research with its distinguished history of discovery and innovation today remains an essential part of VA’s efforts to ensure the health and well-being of our Nation’s veterans. 

VA takes great pride in research that keeps it at the forefront of 

modern medicine and healthcare and expects to see further remarkable discoveries in the future. 

Mr. Chairman, that concludes my statement and I will be 

pleased to respond to any questions you or the Subcommittee Members may have. Thank you. 

[The prepared statement of Dr. Kupersmith appears on p. 55.] 


wwoods2 on PRODPC68 with HEARING
26 

Mr. MICHAUD. Thank you very much, Dr. Kupersmith. You are 

actually saved by the bell. So I will be submitting my questions for 

the record as will Ranking Member Miller as well. 

Dr. Snyder. 

Mr. SNYDER. I am sure other Members may have questions for 

the record also. 

Dr. Kupersmith, the issue of the funding has been kind of a nod 

at some of us over the last several years because I thought the 

President’s budgets have always been grossly inadequate. They do 

not keep up with the medical inflation rate or whatever that term 

is, the research inflation rate. They include funding that, you 

know, they just anticipate that there is going to be robust funding 

from NIH and other agencies or private funding. Those budgets 

were inadequate also. 

So we have a catch-up phenomenon going on. But I mean, do we 

not still have some more work to do in terms of overall funding and 

what could be done given all the things that you just outlined, the 

challenges that our veterans and our new generation of veterans 

are facing? Would you all not benefit from additional funding? 

Dr. KUPERSMITH. Well, as you know, I support the President’s 

budget. I can certainly tell you—— 

Mr. SNYDER. My question was, will you not benefit from additional funding? 

Dr. KUPERSMITH. I am sorry? 

Mr. SNYDER. My question, though, was, I understand you are 

supporting the budget, but my question was, would you all not be 

able to do additional good things if you had additional funding? 

Dr. KUPERSMITH. Yes. Yes. The answer is yes. Certainly I think 

our portfolio is moving certain directions which I think will be very 

beneficial to veterans and others in the future. We are obviously 

moving more toward conditions related to OIF/OEF and research 

on that level. 

We always balance our portfolio between the newer veterans 

coming back or we have in the past few years and the chronic diseases that veterans have. And genomic medicine actually bridges 

both of those. Some of our first projects in genomics will be on 

PTSD and TBI. 

And so some of the things that were mentioned today, pain, for 

example, we have been increasing our portfolio on that and we are 

very interested in that. We even have it as part of our Research 

Career Development Award Program. 

So the answer is, yes, we do have a number of things that we 

would do. 

Mr. SNYDER. Is it not a question not just of projects? I mean, I 

assume that you have a good system for sorting through, okay, we 

have this many research projects from around the country that we 

could fund. We think we are going to come up with our list of ones 

that we think are good. We have adequate funding for this many. 

There are still some we would like to fund. I mean, that is part of 

it. 

But is not another part of it, unless we have robust funding, researchers are going to find other places to go to and other countries 

to go to and private sector places to go to? Is that not an issue, too, 


wwoods2 on PRODPC68 with HEARING
27 

that we need to have robust, reliable funding so that to keep the 

kind of personnel that you want at the VA? 

Dr. KUPERSMITH. Surely it is. And I think that, you know, it is 

both. And I will answer that if we had more money, we would— 

you know, the retention of physicians is a very important part or 

research is a very important part of retention of physicians in the 

VA and our research program in general. Obviously researchers go 

where there is funding. And, you know, again, we support the 

President’s budget. If we had more funding, those are some of the 

things that we would think about certainly. 

Mr. SNYDER. Thank you, Mr. Chairman. 

Mr. MICHAUD. I would like to thank this panel as well and the 

two previous panels for your testimony today. And we will submit 

additional questions for the record. 

Dr. KUPERSMITH. Can I just ask one? May we respond to some 

of the questions that were asked to the other panelists? We would 

appreciate that opportunity also. 

Mr. MICHAUD. In writing, yes. 

Dr. KUPERSMITH. Yes. 

Mr. MICHAUD. Yes, absolutely. 

Dr. KUPERSMITH. Thank you very much. I appreciate that. 

Mr. MICHAUD. This hearing is adjourned. Thank you. 

[Whereupon at 11:27 a.m., the Subcommittee was adjourned.] 


wwoods2 on PRODPC68 with HEARING
(28) 

A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, 

Chairman, Subcommittee on Health 

At this hearing, we will examine the Department of Veterans Affairs Research 

Programs. 

Research is one of the core missions of the Veterans Health Administration 

(VHA). The VA is unique, in that it has the capability to provide clinical services 

and conduct research within the same organization. As a result, the VA has done 

ground-breaking research on topics ranging from post-traumatic stress disorder, 

prosthetics, smoking cessation and treatment of heart disease. 

The purpose of this hearing is to examine VA research programs, particularly in 

light of the current conflict. As we all know, Operations Enduring and Iraqi Freedom have presented us with some new challenges in caring for and treating injured 

soldiers. In recent years, we have seen a dramatic increase in the number of returning veterans with conditions such as PTSD, TBI, and traumatic amputations. 

These conflicts have produced nearly 28,000 severely injured veterans, over 700 

of which have had traumatic amputations. It is vital that the VA continue to push 

the edge of research in order to provide these brave men and women with the most 

up-to-date care available—whether they need prosthetics, pain-management, eyecare, or any number of other services. 

It is also important that the VA work in collaboration with the Department of Defense, academic partners and other public and private entities to leverage their resources and knowledge—and to produce the best research possible. 

I would like to send a special welcome to one of our witnesses today. 

On the 21st of June, 2003, Major David Rozelle was leading a convoy west of 

Baghdad when his vehicle struck a landmine, which resulted in the loss of his right 

foot. After spending 8 months recovering at Fort Carson, Colorado, Major Rozelle 

returned to Iraq as a Troop Commander conducting operations in Baghdad and Tal 

Afar—he was the first troop commander to redeploy to the same battlefield as an 

amputee in recent military history. 

Major Rozelle is currently serving as an Administrative Officer at the Military Advanced Training Center at Walter Reed Army Medical Center. Drawing on his personal and professional experience, Major Rozelle helped plan and design this brand 

new facility—using the most state-of-the-art research available. 

Welcome, Major Rozelle. 

Continued research is vital to improving healthcare, saving lives and improving 

the quality of life for our sick and injured. I look forward to hearing from our witnesses about what the VA is doing—and what the VA should be doing—to advance 

their core mission of research. 

f 

Prepared Statement of Hon. Jeff Miller, Ranking Republican Member, 

Subcommittee on Health 

Research is necessary to generate new knowledge and achieve scientific and clinical excellence. 

The Department of Veterans Affairs (VA) is world renowned for its medical research, and VA’s research program has a strong history of success and is credited 

with pioneering life saving therapies and treatments that have improved health care 

not only for veterans but for patients as a whole. This year, for example, the first 

vaccine for shingles was approved as a result of VA research. 

Modern molecular medicine and rapidly advancing medical technology make a 

strong research enterprise more important to veterans than ever. 


wwoods2 on PRODPC68 with HEARING
29 

As we map the future of VA research, we must work to ensure that VA’s research 

goals align with the special health care needs of both our new generation of veterans from the Global War on Terror and our older veterans of previous wars. 

Recognizing the value of VA research, we must also be aware that nothing is more 

important than translating research from the ‘‘bench’’ to the ‘‘bedside’’. 

I am pleased to see that we will hear from the Administrative Officer from the 

Military Advanced Training Center and have the opportunity to discuss collaborative efforts on federal research for the benefit of our military and veterans. 

Thank you, Mr. Chairman, and I yield back the balance of my time. 

f 

Prepared Statement of John R. Feussner, M.D., MPH 

Professor and Chairman, Department of Medicine 

Medical University of South Carolina, Charleston, SC 

and Volunteer Staff Physician, Ralph H. Johnson Veterans Affairs Medical 

Center on behalf of Friends of VA Medical Care and Health Research 

Good morning Mr. Chairman and members of the committee. My name is John 

Feussner, and I am Professor and Chairman of the Department of Medicine at the 

Medical University of South Carolina in Charleston. I am also a volunteer staff physician at the Ralph H. Johnson VA Medical Center and was the Department of Veterans Affairs Chief Research and Development Officer from 1996 until 2002. I am 

testifying on behalf of the Friends of VA Medical Care and Health Research (FOVA), 

a coalition of over 80 organizations dedicated to ensuring that America’s veterans 

receive the highest quality health care by promoting the long-term sustainability of 

the VA Medical and Prosthetics Research Program. 

On behalf of FOVA, I want to thank the members of the committee for the opportunity to present the coalition’s views on the importance of the VA research program 

and the challenges the program faces in the upcoming years. In addition, I wish to 

thank the Committee for its support of the VA Medical and Prosthetics Research 

program, as evidenced by your recommendation of a $480 million appropriation for 

VA research for fiscal year (FY) 2008. The support for this program across party 

lines is indicative of its success and the common understanding of the importance 

of the program for America’s veterans. FOVA encourages Congress to deliver the appropriations bill funding the VA medical care and research programs to President 

Bush quickly so veterans and researchers will not have to wait for access to appropriate resources. 

The VA Medical and Prosthetics Research Program is one of the nation’s premier 

research endeavors, attracting high-caliber clinicians to deliver care and conduct research in VA health care facilities. The success of the VA program—which can be 

seen in the array of achievements attributed to VA researchers, such as the invention of the implantable cardiac pacemaker, the creation of a new vaccine for shingles, and the development of state-of-the-art prosthetics, including a new bionic 

ankle—is a function of its structure, leadership, and the secured availability of resources. 

The VA research program is an intramural program; grantees must be VA employees with at least a five-eighths appointment to the VA. The program, therefore, 

offers a dedicated funding source to attract and retain high-quality physicians and 

clinical investigators to the VA health care system, who in turn provide first-class 

health care to our Nation’s veterans. With this effective mechanism for attracting 

top researchers, VA has been able to make significant advances in areas of research 

that benefit the veteran population. VA investigators have been at the forefront of 

research that impacts newly returning veterans from Operation Iraqi Freedom and 

Operation Enduring Freedom, including research on post-traumatic stress disorder, 

polytraumatic blast injuries, and massive burns. In addition, VA has taken the lead 

on issues affecting the aging population of veterans who continue to constitute the 

largest portion of veterans seeking treatment in the VA system. Investigators in the 

VA research program have contributed to significant advances in pain management, 

substance abuse treatment, mental health disorders, respiratory medicine, diabetes, 

and Alzheimer’s disease. 

FOVA would like to stress the importance and value of the VA program’s peer 

review system in articulating the agency’s research portfolio. Congress may encourage VA to consider new research areas; however, it is vital to the integrity of the 

program that scientific merit remains the predominant criteria for funding. Peer review of proposals ensures that VA’s limited resources support the most meritorious 

research. Additionally, centralized VA administration provides coordination of VA’s 

national research priorities, aids in moving new discoveries into clinical practice, 


wwoods2 on PRODPC68 with HEARING
30 

and instills confidence in overall oversight of VA research, including human subject 

protections, while preventing costly duplication of effort and infrastructure. 

While VA has been effective in its mission to provide the best possible care to the 

nation’s veterans, veterans from the current wars in Iraq and Afghanistan are returning with injuries and conditions that will require treatment over many years. 

Additionally, veterans are returning with injuries never before experienced in such 

severity, which require additional research, and in turn, additional resources. FOVA 

greatly appreciates this Committee’s support for the program in FY 2008; however, 

the $480 million appropriation only provides a starting point when consideration is 

given to long-term inflationary pressures. 

To fund new research while still supporting traditional research areas that benefit 

the majority of veteran patients, FOVA encourages Congress to support significant 

increases to the program over the next three years. Additional funding can support 

research into such issues as traumatic brain injury (TBI), mental health treatment 

of veterans, and the effects of limb loss on other co-morbid conditions. Research is 

needed to understand the physical and psychological effects of TBI injuries and 

long-term funding is required to conduct post-deployment surveillance for TBI. Research into the potential long-term effects of exposures and risk factors among veterans of hazardous deployments can offer potential treatments for returning veterans while leading to the development of preventative medicine for future deployments. Advances in VA’s rehabilitative research portfolio can improve treatment for 

paralysis and lead to greater limb function in injured veterans. 

Additional funds could also restore previous funding levels for scientific awards. 

Due to previous years of inadequate funding, VA capped scientific awards at 

$125,000 annually. This level of grant support—which is barely enough to hire one 

laboratory technician and purchase necessary supplies—is significantly lower than 

the average grant awarded by other federal granting agencies. The amount diminishes productivity, slows the translation of research from the bench to the bedside, 

and hinders recruitment to the VA program. 

Moreover, while the promise of medical research lies in the potential to create 

new treatments and cures for diseases and injuries, these efforts are not achieved 

by one grant or project. Research is a long-term ambition that cannot be fully successful in one funding cycle but must be sustained if treatments are to be discovered. FOVA encourages the Committee to consider the long-term needs of VA investigators when promoting future funding allocations for the program. As most VA research awards are three years in duration, the coalition encourages Congress to consider a planned growth for the VA research budget over the course of the next three 

years to continue the upward trajectory of the program in an orderly fashion. 

However, even with sustained growth, VA will be ineffectual in advancing new 

treatments if it does not have the appropriate infrastructure in place. For years, VA 

has been aware of the inadequacies of its research infrastructure. An internal review of the infrastructure of VA laboratories was implemented in 2001 when I was 

at Central Office. The Research Evaluation Project assessed the state of the research infrastructure by surveying sites on the quality of the physical infrastructure, the organization structure in place to support research, and the availability 

of biomedical equipment. Based on that evaluation and the list of necessary improvements subsequently compiled, your predecessors and I reached an understanding that a dedicated funding allocation of $40 million a year was required to 

maintain VA research facilities. In May 2004, then Secretary of Veterans Affairs 

Anthony J. Principi approved the Capital Asset Realignment for Enhanced Services 

(CARES) Commission report that called for enhancement of VA research space, and 

this Committee and appropriators have called on VA to update these studies. 

Under the current system for funding infrastructure improvements, research must 

compete in the minor construction budget with other facility needs. This system has 

led to an even greater accumulation of necessary research facility upgrades including improved ventilation, electrical supply, plumbing, and space configuration. 

FOVA applauds the Committee for recommending a $15 million minor construction 

funding stream for research facilities in its views and estimates for the FY 2008 

budget. This step certainly brings needed attention to this matter. FOVA recommends at least a $45 million allocation for research facilities improvements under 

the minor construction account. Considering the significant needs recognized in 

2001, this level of funding would just begin to address the agency’s infrastructure 

problems. 

While VA can take advantage of its relationships with affiliated medical schools 

and non-profit foundations to garner additional funding for infrastructure improvements, these funds are limited and VA must assume responsibility for the cost of 

its own research facilities. Based on preliminary accounts of yet another survey assessing VA research facilities, FOVA is under the impression that at least half of 


wwoods2 on PRODPC68 with HEARING
31 

the facilities received failing grades, which signifies that dedicated minor construction funding is vital to sustainability of the program. 

There are a number of examples of the poor state of research laboratories in the 

VA system. When an animal facility is too small, investigators bring the animals 

into their regular laboratories, exposing themselves and staff to occupational illnesses. Occupational Safety and Health Administration (OSHA) inspectors have expressed concerns about VA research facilities and, in one case, said that if it was 

up to OSHA, the building would be shut down. Meanwhile, a researcher in Seattle, 

Washington, received a grant that required storing tissue samples in sub-zero freezers. Space was allocated, but the facility was unable to provide $30,000 to upgrade 

the electrical system to support the freezers. VA researchers in Gainesville were unable to conduct certain types of research because their ‘‘wet lab’’ countertops are 

made of particleboard and Formica, rather than the standard stone, and are easily 

burned and stained from exposure to heat and chemicals. 

Substandard facilities make VA a less attractive partner in research collaborations with affiliated universities, reduce VA’s ability to leverage the research and 

development appropriation with other federal and private sector funding, and make 

it difficult to attract cutting edge researchers to pursue careers in VA. Facility R&D 

Committees regularly disapprove projects for funding consideration because the facility does not have the necessary infrastructure and has little prospect of acquiring 

it. Upgrading facilities should proceed hand-in-hand with increasing funding for the 

VA research program to yield successful outcomes important to veterans and all patients. 

Again, thank you for the opportunity to present FOVA’s views on the VA research 

program. I look forward to your questions. 

f 

Prepared Statement of Major David Rozelle, 

Administrative Officer, Military Advanced Training Center, 

Walter Reed Army Medical Center 

Department of the Army, U.S. Department of Defense 

Chairman Michaud, Congressman Miller, and distinguished Members of the subcommittee, thank you for inviting me to participate in this hearing alongside my colleagues from the Department of Veterans Affairs (VA). I am Major David Rozelle, 

an Armor Officer and Administrative Officer of the Military Advanced Training Center at Walter Reed Army Medical Center. I am excited to talk with you today about 

the use of advanced technology at the MATC and at the Center For the Intrepid 

(CFI) at Brooke Army Medical Center in San Antonio, Texas. The openings of the 

CFI on the 29th of January 2007 and the MATC on September 13, 2007, were noteworthy events that demonstrated the tremendous support of the American people 

for our wounded warriors. These facilities are also representative of the significant 

advances that are being made in the care provided to our courageous servicemembers. Although the two centers mirror each other in capabilities, the CFI is 

monumental in appearance while the MATC is strictly utilitarian. The MATC, however, will eventually move its capabilities to a more permanent home once Walter 

Reed closes. 

One patient recently described the interior of the MATC as ‘‘where the magic happens.’’ It is a mix of technology and philosophy that allows our warriors to return 

to a lifetime of the highest physical, psychological and emotional function. Each 

servicemember is treated as a ‘‘tactical athlete’’—the MATC brings the latest advances in sports medicine to bear on their treatment. Within the walls of the MATC 

there is a multidisciplinary health professional team that works together to 

seamlessly bring the patient from recently wounded status to a return to warrior 

status. This team includes representatives from the Veterans Benefits Administration, VA Social Workers, and VA Vocation Education and Rehabilitation counselors. 

While the team includes those thought to be part of the traditional rehabilitation 

team—the physical therapists, occupational therapists, physiatrists, and nurse case 

managers—it also includes psychological liaison providers, biomechanists, the patients, the patients’ family members, and others. 

The facilities boast many ‘‘state-of-the-world’’ or ‘‘state-of-the-art’’ capabilities: 

• The fire arms training simulation room utilizes Blue Tooth technology to replicate the weight, feel and response of actual weapons, the M16 and M14 rifles 

and the 9mm pistol. This allows the servicemember to regain confidence in their 

ability to carry out the roles of a combat Soldier. It is also utilized to clear individuals prior to their participation in some of the outdoor recreational activities 

like skeet shooting and hunting. 


wwoods2 on PRODPC68 with HEARING
32 

• The gait labs are among the largest and most sophisticated in the world. With 

a 23 camera capture system, a dual force plate treadmill, and force plates of 

different sizes arranged in an array in the floor, the gait lab is able to analyze 

the gait patterns of our clients while they utilize a variety of prosthetic components and apply the results to both prosthetic adjustments and to physical therapy and occupational therapy treatment plans. 

• The Computer Assisted Rehabilitation Environment or CAREN System is another ‘‘state-of-the-art’’ technology that provides tremendous potential for our 

clients. Imagine a helicopter simulator and replace the helicopter with a platform and an imbedded treadmill with dual force plates under the treadmill. 

Now link this through a computer system to a screen that projects an image 

which is linked to your actions as you move on the platform. We can have you 

walking up and down a hilly trail with the platform shifting to mirror the 

changes on the screen, if you speed up the system detects it and speeds up both 

the projection and the treadmill, if you slow down the system responds accordingly. It can generate a city street scenario, beginning with walking down a 

quiet street, then adding in stressors, additional people, cars backfiring, trash 

on the side of the road, pedestrian tunnels, and allow our psych staff to work 

with you as you approach these stressors. This is a new and exciting technology 

that is applicable not only to our patients with limb loss, but also those with 

traumatic brain injury or combat stress. 

• The facility offers a variety of opportunities to work on advanced skills that are 

applicable to both leisure activity and military skills. This includes both a 

climbing wall and a treadwall—the climbing wall adds the challenge of functioning at height while the treadwall challenges the patient cardiovascularly. 

• The SoloStep is an overhead support system that permits the patients to be 

supported as they progress from walking to running. The MATC offers the only 

Solostep system in the world that goes in a continual loop. Rather than a 20 

foot straight run where the patient has to continually stop and turn around, 

ours goes around the entire length of our track. This support system frees the 

therapist from having to hold the patient as they ambulate and allows the therapist to watch the patient and make immediate corrections to their gait. 

• Elevating parallel bars were developed specifically for the military amputee patient population. The Army Medical Department has the only three sets in the 

world. This allows the patients to train for community obstacles which they will 

frequently encounter such as sloping streets, sidewalks, or ramps. These also 

will play a significant role in research efforts to provide our warriors with more 

functional prosthetic devices. 

• A vehicle simulator is available to provide the initial training with hand controls. We collaborate with the VA, who will provide the follow on training out 

on the street in actual vehicles. One of our staff members, a VA employee, has 

developed software programs for the simulator to specifically address driving 

issues related to deployment. Known as combat driving, it includes such practices as rolling stops and wide lane changes to avoid obstacles in the road. 

While these are potentially life saving measures in theater, they may be extremely dangerous if practiced stateside. By working on modifying these behaviors on the simulator we are able to better prepare our patients for a return 

to driving. 

A very active community reintegration program has been developed which includes a variety of activities from field trips to a museum or a mall or a wide range 

of sports activities to include skiing, kayaking, scuba, cycling, mountain climbing, 

and surfing. This was a lesson learned during the Viet Nam war as the military 

worked to help patients return to the civilian community. The success of that program has kept it an integral part of the military amputee rehabilitation process. Another program that has been very successful is our running program, training our 

clients for a range of distance races, biathlons, and triathlons. 

As mentioned earlier, much of our success is due not to the technology advances, 

but to the philosophy and approach to patient care. Again, during the Viet Nam war 

it was identified that having the patients work in larger cohort groups appeared to 

have greater benefit than working independently, close to home. Many veterans 

with limb loss from previous wars have volunteered to be peer visitors for our patients. This ability to see the future, whether it is seeing a recently injured warrior 

who is one or two months ahead of you, or seeing the more distant future provided 

by the peer visitors, provides a sense of purpose and focus for our patients to strive 

toward. 

Technology has played a significant role in prosthetic restoration. New methods 

of measurement have resulted in more efficient methods of measuring the serviceVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00036 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
33 

member’s amputated limb with better precision, efficiency, and quality. These methods include Computer Aided Design Computer Aided Manufacturing (CADCAM), optical digitizing and stereo lithography where CT Scans are digitized and used to 

print an accurate 3 dimensional model of the residual limb including any existing 

heterotopic ossification. Additionally, the treatment for servicemembers in the Global War on Terror has resulted in current technology being utilized in new ways. The 

U.S. Armed Forces Amputee Patient Care Program at WRAMC was the first in the 

world to utilize the micro-processor prosthetic knee as an early rehabilitation knee 

unit, providing newly injured servicemembers increased stability, safety and confidence in the use of a prosthetic limb. 

The Program pioneered and implemented the use of the Military Ambulatory Diagnostic Prosthesis philosophy for the lower limb amputee. Under this philosophy, 

the prosthetic sockets are rapidly produced with extremely durable temporary materials and coupled with the most technologically advanced components. The patients 

receive multiple and frequent sockets to accommodate the volume and shape 

changes common during the early post-operative phases. 

Similarly, with upper extremity limb loss, the concept of Early Post-Operative 

Prosthesis was resurrected and coupled for the first time with a policy of utilizing 

external powered prosthetic components. The use of myo-electric prosthetic components instead of body powered components places much less stress on the residual 

limb and permits the patient to begin to train much earlier in the rehabilitation 

process. The ability to rapidly manufacture and change sockets to accommodate 

upper extremity residual limb changes has permitted our patients to continue to use 

a prosthesis throughout the early stages of rehabilitation and makes them much 

less likely than their civilian counterparts to reject prosthetic use. 

The innovative use of current state of the art technology has attracted many manufacturers to the program. These manufacturers are seeking to provide new technology to the program prior to release to the general population. The early release 

of this technology allows the military prosthetists to obtain critical knowledge of the 

technology and provide expert feedback to the manufacturer. 

The current emphasis on care of the military amputee patient has stimulated the 

application of a wide range of advanced technologies into the development of enhanced prostheses, which can much more closely simulate the human body. 

Collaboration between the DoD and the VA is ongoing and has already led to several significant successful projects. Among these is the development of the VA/DoD 

Clinical Practice Guidelines (CPG) for Care of the Amputee. This CPG sets in place 

the clinical pathway for both pre and post amputation patient care. Additionally, the 

establishment of a VA/DoD Clinical Rotations Program allows for rehabilitation 

practitioners (physical therapist, occupational therapist and prosthetist) all from the 

same Veteran Integrated Service Network (VISN) to train as a team simultaneously 

with counterparts at MATC and the CFI. This unique program bridges the span between the VA and DoD practitioners and provides an understanding of operations 

at the varying installations which ultimately leads to better care of the injured 

servicemember. 

With the financial support of Congress, we have been able to develop a research 

program that has already provided some exciting developments and, with the advanced care centers, promises to significantly change how we provide warrior care 

in the future. 

Over 82% of amputations in the U.S. occur as the result from complications of diabetes and dysvacular disease, with a greater prevalence rate of individuals over the 

age of 65. Data obtained from OEF and OIF reveal a much different patient population. As of September 2007, there have been over 700 servicemembers, who have 

sustained a major limb amputation in support of GWOT. Twenty-three percent 

(23%) of these individuals have lost an upper limb and over 20% have lost more 

than one limb. Nearly 90% of these servicemembers have been under the age of 35 

and as a result have unique psychosocial needs and generally seek to return to a 

more active lifestyle than older individuals. Additionally the majority of combat related amputations do not occur in isolation. Over 50% have had a documented traumatic brain injury (TBI), some with vision and/or hearing loss, many have significant remote fractures and significant soft tissue wounds, others with co-morbid paralysis from peripheral nerve injury or central cord injury and nearly all with contaminated wounds requiring frequent surgical washouts and extensive antibiotic 

use. These complex medical, surgical and rehabilitation challenges require a unique 

approach to treatment and warrant dedicated research programs to optimize care. 

The advanced training centers have proven to be an ideal setting for training in 

advanced techniques related to amputee care and prosthetics. In addition to the VA/ 

DoD Clinical Rotation Program, we have held a number of courses attended by miliVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00037 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
34 

tary therapists and Veterans Affairs therapists and prosthetists from around the 

country. 

The combination of advanced technologies, innovative clinical practices, caring 

providers and an amazing group of warriors in transition with the strength and 

courage to seek the high ground and continually move forward has led to revolutionary changes in our understanding of the capabilities of individuals with limb 

loss. 

I thank you for inviting me to talk with you today about the capabilities and the 

magic of the Military Advanced Training Center at Walter Reed and the Center for 

the Intrepid in San Antonio. Your continued support for our wounded, ill, and injured is very much appreciated by the Soldiers and staff at Walter Reed and 

throughout the Army. 

f 

Prepared Statement of Mark J. Lema, M.D., Ph.D. 

Chair, Department of Anesthesiology, Critical Care and Pain Medicine 

Roswell Park Cancer Institute, Buffalo, NY, Professor and Chair, 

Department of Anesthesiology, University of Buffalo, State University of 

New York, School of Medicine and Biomedical Sciences, and 

President, American Society of Anesthesiologists, 

on behalf of Pain Care Coalition 

Mr. Chairman and members of the Subcommittee, my name is Mark J. Lema, 

M.D., Ph.D. I am Chair of the Department of Anesthesiology, Critical Care and Pain 

Medicine at the Roswell Park Cancer Institute in Buffalo, New York, and Professor 

and Chair of the Department of Anesthesiology at the University of Buffalo, State 

University of New York, School of Medicine and Biomedical Sciences. I also serve 

as the current President of the American Society of Anesthesiologists. 

I am pleased to testify today on behalf of the Pain Care Coalition, a national advocacy effort of the American Academy of Pain Medicine, American Pain Society, 

American Headache Society and American Society of Anesthesiologists. Collectively, 

these organizations represent more than 50,000 physicians and other clinicians, researchers, and educators who provide clinical leadership in the increasingly specialized field of pain management. Some of these individuals work either full or part 

time in the VA health system, and many others are involved in collaborative relationships with research and clinical care programs throughout the VA system. 

We appreciate the opportunity to appear today and present our views on the state 

of pain research at the VA. As professionals in the pain care field, nothing we do 

is more important than assuring that those who serve our country in times of war 

get the very best pain care possible during all stages of their service, and in all settings of the military and veteran health and medical systems. These settings range 

from the battlefield to the clinics, hospitals, rehabilitation centers and long term 

care facilities of the VA. As a complement to these clinical care responsibilities, 

those of us in pain medicine have a continuing interest and responsibility in pain 

care research within the VA’s Medical and Prosthetic Research Program, as well as 

other public and private research efforts with which the VA collaborates. 

THE SCOPE OF THE PAIN PROBLEM 

Pain is a very large public health problem in this country. It is the most common 

reason people access the medical care system, a major cause of lost productivity in 

the workplace, and a substantial contributor to short and long term disability. It 

affects Americans at all stages of life and in all walks of life. For example, 26 million Americans of working age have frequent back pain, and chronic back pain is 

the leading cause of disability for those under 45 years of age. Twenty-five million 

suffer from migraine headaches. Four million, mostly women, suffer from a complex 

pain syndrome known as fibromyalgia. Forty million have arthritis pain. 

Pain imposes a terrible burden on those who suffer and on their families, and it 

imposes large costs on the health care and disability income systems. Medical costs 

and lost productivity alone are estimated to top $100 billion annually. Pain is often 

poorly understood by those who suffer and by those around them. It is often 

undiagnosed or misdiagnosed, and under-treated or mistreated. Sometimes pain is 

the symptom of other diseases as in the case of cancer, arthritis, heart disease, and 

diabetes. Other times, pain is the disease itself as with migraine, chronic back pain 

and various diseases associated with damage to the nervous system, such as postherpetic neuralgia, diabetic neuropathy, or injuries to the nervous system such as 

commonly occur in combat, including phantom limb pain, post-injury or post-surgery 

neuralgias, and traumatic brain injury. 


wwoods2 on PRODPC68 with HEARING
35 

The most recent complete study of soldiers enrolled in VA Polytrauma Centers 

show that more than 90% have chronic pain, that most have pain from more than 

one part of the body, and that pain is the most common symptom in returning soldiers. Advances in neuroscience, such as neuroimaging, now demonstrate that 

unrelieved pain, regardless of its initial cause, can be an aggressive disease that 

damages the nervous system, causing permanent pathological changes in sensory 

neurons and in the tissues of the spinal cord and brain. 

Pain can be acute and effectively treated by short term interventions, or it can 

be chronic, often without effective ‘‘cures’’ and sometimes without consistent and effective means of alleviation. Those who suffer severe chronic pain see their daily 

lives disrupted—sometimes forever. Their pain and their constant search for relief 

affects their function, their relationships with those they love, their ability to do 

their work effectively, and often their self esteem. Chronic pain is often accompanied 

by or leads to sleep disorders, emotional distress, anxiety, depression, and even suicide. 

If these facts are true in the general population, which we know them to be, then 

they are doubly true in the military and veteran populations. The physical and emotional stresses of military service make inevitable the disproportionate incidence of 

both acute and chronic pain among active duty personnel. If miners, movers and 

construction workers suffer low back pain from heavy lifting, imagine the toll on the 

spine of those in active duty combat situations. If truckers develop back pain from 

long hauls, imagine the toll of armored vehicles going long distances on poor or nonexistent roads. If the stresses of daily civilian life serve as triggers for those suffering severe migraine, imagine the impact of battlefield conditions. 

The incidence of acute pain among those injured in current conflicts will be virtually 100%, and for far too many, the original short term trauma will be followed 

by chronic pain of significant dimension and duration. For example, virtually all of 

those suffering the loss of one or more limbs in combat will suffer from phantom 

limb pain. While this can be managed with varying degrees of effectiveness, there 

is no known ‘‘cure.’’ Virtually all veterans fitted with prostheses will suffer some degree of pain at the device/body ‘‘interface.’’ Again, this can be managed to some degree, but it is rarely eliminated. 

Far less visible, but even more prevalent, is the extensive damage to the central 

and peripheral nervous systems resulting from the horrific explosive devices deployed in the current conflicts. Unlike broken bones, flesh wounds and burns, many 

of which will eventually heal after aggressive treatment, extensive nerve damage 

may only be manageable, not curable, given the current state of science and clinical 

practice. Most returning veterans with extensive nerve damage will be chronic pain 

sufferers and will require long term pain management, with varying prognoses for 

success. Ironically, the proportion of these chronic pain sufferers among returning 

wounded servicemen and women will be far greater in the current conflicts than in 

previous wars because of the remarkable successes of military medicine which now 

keep so many of the very severely injured alive. 

PCC’S INVOLVEMENT IN PAIN MANAGEMENT FOR VETERANS 

On the battlefield and upon returning home from service, critically wounded men 

and women must receive the best, most advanced pain management interventions 

available. Members of the Pain Care Coalition have made significant contributions 

toward efforts to alleviate the suffering of our brave soldiers. 

For example, Lt. Col. Chester ‘‘Trip’’ Buckenmaier III, an Army anesthesiologist 

and member of the American Society of Anesthesiologists, has been at the forefront 

of providing revolutionary pain care to wounded veterans. During a deployment to 

Iraq several years ago, Dr. Buckenmaier used portable infusion pumps to alleviate 

the pain of soldiers with grave injuries to their arms and legs. In a recent Wall 

Street Journal article, Dr. Buckenmaier described a situation in which a soldier 

changed his evaluation of his pain from 10 on a 10 point scale—‘‘the worst pain 

imaginable’’—to zero, after being treated with a portable infusion pump. 

This example underscores the life-saving, life-changing pain management techniques increasingly used in military medicine. In fact, during an October 2005 hearing of the House Committee on Armed Services, Deputy Surgeon General Joseph G. 

Webb, Jr., highlighted the advances of pain medicine benefiting our soldiers. He 

said, ‘‘Wounded soldiers in Iraq and Afghanistan benefit from receiving some of the 

most advanced technologies and techniques in medicine today . . . The benefits of 

advanced pain management, during and after surgery, are improved postoperative 

outcomes and the potential to eliminate chronic pain, particularly in amputees.’’ 

Dr. Buckenmaier’s story and Major General Webb’s testimony illustrate the potential and the challenge of deploying innovative and advanced pain management techniques to treat our veterans. 


wwoods2 on PRODPC68 with HEARING
36 

THE VA’S CURRENT PAIN RESEARCH EFFORT 

Perhaps more than any other federal agency, the VA has been a leader in focusing 

institutional resources on the assessment and treatment of pain. Under a ‘‘National 

Pain Management Strategy’’ initiated in November 1998 (‘‘Strategy’’), and pursuant 

to VHA Directive 2003–021, the Veterans Health Administration has made pain 

management a national priority. Among the specific objectives of the Strategy are: 

• providing a system-wide standard of care to reduce suffering from ‘‘preventable’’ 

pain; • ensuring consistency in the assessment of pain; • ensuring prompt and appropriate treatment for pain; • promoting an inter-disciplinary approach to pain management; and • providing adequate training to and resources for clinicians in VA healthcare to 

achieve these objectives. 

The Pain Care Coalition applauds the Strategy and generally supports its specific 

goals and objectives. At the same time, the Coalition has significant concerns with 

the current VA effort: 

• Directive 2003–021 is only a five-year plan. It is scheduled to expire in May of 

2008; • there has been, to the Coalition’s knowledge, no comprehensive assessment of 

the Strategy’s strengths, weaknesses and accomplishments; and • reports from the field suggest that implementation has been far from consistent. 

Some VA facilities have made great strides in improving pain care, while for 

others it is more an aspirational goal than an operating reality. As a result, veterans get widely different treatment for pain depending on the expertise and 

resources of the particular VA facility at which they receive their care. 

Significantly, and directly germane to the Subcommittee’s current inquiry, the 

Pain Care Coalition believes that, in order to ensure effectiveness, the VA’s 

pain management Strategy must be accompanied by and integrated with a 

significant research commitment to advancing the science of pain care, and 

to translating developments in the science to improved clinical care 

throughout the system. 

The VA has had a long and continuing research interest in the phenomenon of 

phantom limb pain, with current work focused at the molecular level. It also has 

current research efforts in neural repair, which might someday lead to improvements in therapy for those veterans currently returning with significant damage to 

the nervous system. And it recently completed a successful study of the effectiveness 

of a shingles vaccine in older veterans which validated research findings elsewhere, 

and will improve care in the general population. Other important pain research initiatives are scattered amongst NIH research institutes. 

In 2006, through an initial grant funded privately, the VA brought together research investigators with interests in pain as part of a VA sponsored conference on 

pain and palliative care. That meeting identified several research interest groups including post-deployment pain, primary care pain programs, and opioid analgesics. 

These groups generated a number of new research projects, several of which have 

earned Merit Award funding through the peer-review process of the VA’s Office of 

Research Development (‘‘ORD’’). Work from these groups also spawned important 

articles in major journals and a special issue of the Journal of Rehabilitation Research and Development devoted to pain research. Based on this success, the VA’s 

ORD funded a second meeting of pain researchers just held in September of 2007. 

At this meeting, researchers identified other important projects which demonstrated 

the breadth and depth of research that is possible if a focused effort is made to organize and promote a VA research agenda dedicated to the basic and clinical sciences 

of pain medicine. I look forward to making the results of this most recent meeting 

available to the Subcommittee in the near future. 

It is imperative that pain research be placed high on the list of current VA research priorities. Alarmingly, the VA’s justification accompanying the Administration’s proposed FY 2008 budget for the Medical and Prosthetic Research Program 

barely mentions pain. The Coalition is aware of no VA data to show what proportion 

of the research budget is devoted to pain, but we suspect it is a very small percentage. 

The VA has identified four research priorities related to the current conflicts: 

• polytrauma; 

• neurotrauma; 

• burns; and 

• chronic illness generally. 


wwoods2 on PRODPC68 with HEARING
37 

Three others are considered continuing priorities relevant to these and all preceding conflicts: 

• prosthetics; 

• PTSD; and 

• vocational rehabilitation. 

Pain is central to each of these seven priorities, and effective pain management is crucial to the restoration of a reasonable quality of life for all 

of these conditions, but there is little indication that pain research has 

been integrated with other research efforts in these seven areas, or coordinated across these and other research programs. 

Unfortunately, pain is not an area where the VA’s leveraged research approach 

can rely on leadership from research partners at the NIH or in private industry. 

For example, despite the documentation that chronic pain is one of the most costly 

of all health problems to the U.S. economy, a recently conducted review of the NIH 

pain research portfolio showed that only 1% of NIH’s annual research funding is devoted to projects with a primary focus on pain. If projects where pain is a secondary 

concern are added, it only rises to 2%. There is no Institute or Center at NIH to 

provide a central home for pain research, and efforts to coordinate pain research 

across the various institutes and centers are in the very early stages of development. 

While private industry has significantly advanced drug and device therapies for 

particular types of pain or classes of pain patients, industry alone can not be expected to carry the load of long term basic science research needed to better understand the mechanisms of pain, and in particular how chronic pain syndromes develop despite successful treatment of the original trauma. 

RECOMMENDATIONS OF THE PAIN CARE COALITION 

The Pain Care Coalition believes the VA’s pain research effort can and must be 

significantly enhanced. We urge the Subcommittee to develop targeted legislation 

with several basic components. 

First, the Congress should require the VA to establish within the Medical and 

Prosthetic Research program at VA headquarters a focused program of research and 

training directed at acute and chronic pain. That program should identify research 

priorities in pain most relevant to veterans returning from the current conflicts, and 

should promote and coordinate basic and applied research on these priorities both 

within the VA, and with its research partners. The same centralized pain research 

program should boost education and training of VA personnel to ensure that research advances are rapidly disseminated throughout the VA care system. 

Second, Congress should authorize and the VA should designate an appropriate 

number of cooperative centers throughout the country for research and education on 

pain. Each such center should take the lead on a priority area of basic science research on pain, or an aspect of acute or chronic pain most relevant to veterans returning from the current conflicts. At least one of the centers should be designated 

as the lead center for research on pain attributable to central and peripheral nervous system damage, and one such center shall be designated as the lead center to 

coordinate the work of all the centers. 

Third, Congress should authorize these newly created pain research centers to 

compete on an equal basis with other priority research areas (TBI, PTSD, 

polytrauma, prosthetics and others) for funds appropriated each year to the Department’s overall medical and prosthetic research budget. 

CONCLUSION 

Mr. Chairman and members of the Subcommittee, pain is often characterized as 

an invisible disease—we can not see it, and unlike such diseases as cancer, diabetes, 

and heart disease, there are no affordable and widely available lab or imaging tests 

to confirm its presence and quantify its severity. But that’s no excuse for letting research efforts lag behind those of other priorities. The Pain Care Coalition is committed to advancing the practice of pain management. We strongly support new and 

increased efforts within the VA’s research, education and clinical care programs to 

ensure that our brave men and women returning from combat receive the best pain 

care possible. The Coalition, along with each of the organization’s it represents, 

stands ready to work with the Subcommittee and the VA toward that end. 

f 


wwoods2 on PRODPC68 with HEARING
38 

Prepared Statement of Thomas Zampieri, Ph.D., 

Director of Government Relations, Blinded Veterans Association 

INTRODUCTION 

Chairman Michaud, Ranking Member Miller, and Members of the House Veterans 

Affairs Subcommittee on Health, on behalf of the Blinded Veterans Association 

(BVA), thank you for this opportunity to submit our testimony on VA Research Programs. BVA is the only congressionally chartered Veterans Service Organization exclusively dedicated to serving the needs of our Nation’s blinded veterans and their 

families. BVA has now worked for more than 62 years with VA Blind Rehabilitation 

Service in order to improve VA’s ability to provide high quality outpatient and inpatient rehabilitation training for blinded veterans. 

BVA appreciated the approval granted earlier this year by former Secretary Nicholson and Under Secretary of Health Dr. Kussman for a three-year, $40 million expansion of the full continuum of blind and low vision outpatient rehabilitation services. With the now growing numbers of wounded entering the VA health care and 

benefits system from both Operation Iraq Freedom (OIF) and Operation Enduring 

Freedom (OEF), along with the large numbers of aging veterans with degenerative 

eye diseases, this expansion of clinical services is vital. 

As of September 25, 2007, a total of 27,767 servicemen and women had been 

wounded in Iraq. The number of men and women requiring air medical evacuation 

from Iraq between March 19, 2003 and September 17, 2007 was 8,298, of which 

1,162, or 13 percent, had sustained combat eye trauma. The 13 percent figure represents the highest percentage of eye wounded for any of the American wars of the 

past 100 years. 

The staggering nature of these numbers reflects the probability that young veterans will, in the very near future, depend on VA blind and low-vision services in 

order to live independently in their own homes and, hopefully, enter the workforce 

once they have fully recovered from their injuries. According to the Defense Veterans Brain Injury Center (DVBIC), some 3,900 of the Traumatic Brain Injured personnel have sustained injuries sufficiently severe that they are experiencing 

neurosensory complications. Epidemiological Traumatic Brain Injury (TBI) studies 

have found that 80 percent of the these 3,900 complain of visual symptoms related 

to their TBI while 62 percent have associated neurological visual disorders of 

diplopia, convergence disorder, photophobia, ocular-motor dysfunction, and an inability to interpret print. Some TBIs result in visual field loss with enough loss to 

meet the standard for legal blindness. Like other generations of disabled veterans 

who have desired to live independently, the current generation of OIF and OEF veterans deserves the same opportunity. 

PREVALENCE AND INCIDENCE OF BLINDNESS 

Low vision or blindness affects one in 28 Americans over the age of 40, which 

amounts to approximately 3.3 million Americans. This 2004 figure, when broken 

down, consists of 2.3 million Americans with low vision and about one million being 

legally blind. Every year, 200,000 Americans develop age-related macular degeneration, which is the most common cause of blindness in people over age 65. Diabetic 

retinopathy is the most frequent cause of new blindness in individuals between 40 

and 65. People who move from visual impairment to blindness have a 50 percent 

greater chance of becoming injured or depressed and a 2.5 to 3 times greater chance 

of needing skilled nursing or a long-term care facility. 

Approximately 648,000 Americans age 80 and older are blind. While only 4.3 percent of the 65 and older population live in nursing homes, 16 percent of those who 

are visually impaired and 40 percent of those who are legally blind reside in nursing 

homes with an estimated cost of close to $11 billion in direct nonmedical costs for 

seniors with visual disorders. By 2020, the number of Americans age 40 and over 

with low vision or blindness is projected to reach 10.5 million, almost three times 

what it was in 2004. 

VA estimates that there are currently 169,000 legally blinded veterans throughout 

the country, of which 47,450 are enrolled in Veterans Health Administration (VHA) 

services. The number is projected to reach 55,000 within 10 years. In addition, 

blindness within the total veteran population of 24 million is expected to increase 

over the next two decades, just as it is increasing within the general American population from glaucoma, macular degeneration, diabetic retinopathy, and cataracts. 

It should be clear to Members of this Committee that a new generation of OIF 

and OEF blinded and impaired low vision veterans will require specialized research 

programs to meet their needs. The older veterans who are now beginning to lose 

their sight have equally important needs. Rehabilitation research programs for both 

groups and their families must be individualized. 


wwoods2 on PRODPC68 with HEARING
39 

ECONOMIC AND SOCIAL IMPACT 

• Of the $68 billion annual cost of vision impairment and eye disease as estimated by the National Eye Institute, the annual financial burden to the American economy of blindness and low vision in adults age 40 and over—driven in 

large part to advanced macular degeneration, cataracts, diabetic retinopathy, 

and glaucoma—is estimated at $51.4 billion. This includes $16.2 billion in direct 

medical costs, $11.2 billion to other direct costs, and $8 billion in lost wages and 

productivity, as well as $16 billion in excess monetary impact due to vision loss. 

The following points illustrate the potential importance of vision rehabilitation 

research in reversing the negative consequences of loss of sight in our veteran 

population. It is seven times more expensive to provide nursing home care for 

a blind individual than for one that is trained and able to function independently at home. Falls associated with vision loss is the sixth leading cause of 

nursing home admissions. 

• ‘‘The Employment Experience of Persons with Limitations in Physical Functioning,’’ a University of California study published in 1999, found that even 

after adjusting for age and gender differences, persons reporting functional limitations are less than half as likely to be in the labor force as those with no functional limitations. Part-time employment and job loss are also more common 

among persons with functional limitations. Three quarters of those experiencing 

a job loss reported that the loss created a major problem in their lives. Only 

half of those with no limitations reported that the problem created by the loss 

was a major one. 

• Literature reviews on employment among persons with disabilities indicate that 

such persons experience lower labor force participation rates, higher unemployment rates, and higher rates of part-time employment than persons without disabilities (Yelin, 1997; Bennefield & McNeil, 1989). These findings are consistent 

across numerous national surveys, including the Current Population Survey 

(CPS), Survey of Income and Program Participation (SIPP), the National Health 

Interview Survey (NHIS), a survey of Trupin and Armstrong in 1998, and a survey of Trupin, Sebesta, Yelin, and LaPlante in 1997. Disabilities in these studies are defined as factors that limit work capacity and functional activity 

(McNeil, 1993). 

• The National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS) and reported in a March 2003 article, revealed 

that working age individuals with visual impairments had lower employment 

rates and lower mean household incomes than those without visual impairments. The employment rate was 54 percent for the severely visually impaired 

age 18–54 in statistics compiled in 1994–95. 

• The National Organization on Disability Research found that, despite improvements in transportation during the past decade, inadequate or inaccessible 

transportation was reported by 30 percent of the disabled. The lack of transportation made employment, social participation, and commercial activities less 

likely, causing increased depression and medical costs. 

• In the aforementioned study, lower mean household incomes and lower employment rates were found among those with disabilities related to mobility (43.3- 

percent rate of employment), agility (46.0-percent rate of employment), speaking 

(41.7 percent employment), mental function or ability to learn (47.5 percent employment), hearing loss disability (62.7 percent employment). 

• A study by Hendricks, Schiro-Geist, and Broadbent (1997) at the University of 

Illinois showed a link between disability and employment outcomes for those 

who had, from 1948 to 1993, completed both a university education and rehabilitation services. Using a regression analysis for those disabled with a degree, 

the study revealed a salary gap of 8.3 percent between disabled and nondisabled 

workers. While this and similar other studies have found that the disabled with 

higher education and rehabilitation earn more than the disabled without this 

level of education and training, the income levels and earning capacity are still 

lower in all comparisons with working age non-disabled individuals. 

• National Council on Disability (NCD) today October 1, 2007, on the first day 

of National Disability Employment Awareness month, released a report that 

presents the best practices in the public and private sectors and the promising 

public policies and initiatives that increase employment opportunities for people 

with disabilities. However, the employment rate of working age people with disabilities remains still only half that of people without disabilities (38 percent 

compared with 78 percent in 2005). 


wwoods2 on PRODPC68 with HEARING
40 

NEUROLOGICAL IMPACT OF TBI DYSFUNCTION 

Perception plays a significant role in our ability to live life. It aids in providing 

information about the properties in our environment and allows us to act in relation 

to those properties. In other words, our perceptions provide us with the means to 

experience our environment and live within it. We perceive what is in our environment by a filtered process that occurs through our complex neurological visual system. Although all senses play a significant role, the visual system is one of the most 

important, providing more than 70 percent of our sensory awareness. With various 

degrees of visual loss, we are no longer able to clearly adjust and see our environment, resulting in increased risk of injuries, loss of functional ability, and unemployment. Impairments range from an inability to successfully navigate one’s visual field 

to loss of visual acuity, loss of color vision, photophobia, and difficulty in recognizing 

faces. 

Among the numerous ways one can acquire visual deficits, and a leading one at 

that, is injury to the brain. Damaging various parts of the brain can lead to specific 

visual deficits. Although some cases have reported spontaneous recovery, complete 

recovery is unlikely and early intervention is critical. Currently complex TBI-visual 

research is being examined in an attempt to improve the likelihood of recovery. The 

training of certain areas of the brain has been found to improve vision deficits in 

some disorders. Nevertheless, researchers have stressed that the extent of recovery 

can be limited and will usually require long term follow-up often with specialized 

adaptive devices and prescriptive equipment. 

The brain is the most intricate organ in the human body. Visual pathways within 

this vital organ are also very complex. Due to the interconnections between the 

brain and visual system, damage to the brain can bring about various cerebral visual disorders. The visual cortex has its own specialized organization, causing the 

likelihood of specific visual disorders if damaged. The occipitotemporal area is connected with the ‘‘what’’ pathway. Thus, injury to this ventral pathway leading to the 

temporal area of the brain is expected to affect the processing of shape and color. 

This can make perceiving and identifying objects difficult. The occipitoparietal area 

(posterior portion of head), on the other hand, relates to the ‘‘where,’’ or ‘‘action’’ 

pathway. Injury to this dorsal pathway leading to the parietal lobe will increase the 

likelihood of difficulties in position (depth perception) and/or spatial relationships. 

In cases of injury, one will find it hard to determine an object’s location and may 

also discover impaired visual navigation. It is also highly unlikely that a person 

with TBI will have only one visual deficit. He/she will usually experience a combination of deficits due to the complexity of the organization between the visual pathway 

and the brain. The most common cerebral visual disorder after brain injury involves 

visual field loss. The loss of peripheral vision can be mild to severe enough to result 

in legal blindness. It requires specific visual field testing to be correctly diagnosed 

and different prescribed devices to adapt to this loss. While the DVBIC reports 

about 10% as severe open head injuries, most TBI cases are closed head injuries 

that can result in a variety of visual deficits from overt to subtle. 

In addition to considering these complex neurological effects on the patient, BVA 

would ask Members of this Subcommittee to consider the huge emotional effects of 

TBI on the servicemember or veteran when deciding what level of support should 

be given to research in this area. These emotional effects may be equaled or even 

surpassed by those inflicted on the patient’s family. Brain injuries are known for 

causing extreme distress on family members who must take on the role of caregiver 

in addition to facing the many other challenges associated with this type of injury 

to a son, daughter, father, mother, brother, sister, or even an extended family member. 

VA MEDICAL AND PROSTHETICS RESEARCH 

BVA has supported investments in veteran-centered research projects within 

VHA. Such projects in the past have led to an explosion of knowledge that has advanced the understanding of many different diseases and unlocked strategies for 

prevention, treatment, and cures. Additional funding is needed to take advantage 

of the burgeoning opportunities to improve the quality of life for our blinded and 

low vision veterans and for the Nation as a whole. VA must concurrently address 

the needs of its longstanding patient base as well as the evolving challenges being 

presented by our newest war-wounded veterans. With increased directed vision research funds, it is expected that VA will begin pursuing the following in Fiscal Year 

2008: new adaptive prosthetics, aging vision diseases, and specialized vision research. This funding increase should also allow for an increase in funding for Rehabilitation Research & Development (RR&D), now so desperately needed with the 

ever-increasing numbers of combat eye injuries. BVA points to the success of new 

retinal research of great importance, the continuation of RR&D initiatives in BosVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00044 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
41 

ton, where investigators are working on the development of artificial retinal implants for those with vision loss due to retinal trauma. 

RECOMMENDATIONS 

Examples of four separate categories identified by the National Alliance for Eye 

and Vision Research (NAEVR) as vital vision research are listed below. NAEVR believes that such research is sufficiently significant that it be supported by Members 

of Congress and utilized by both DoD and VHA. 

Eye Trauma, Healing, Infection/Inflammation Control, and Rehabilitation 

This research relates to acute and chronic implications of corneal and retinal eye 

trauma, healing, infection/inflammation control, and associated vision rehabilitation. 

• Treatment of eye trauma caused by a physical, chemical, or biological agent insult; associated healing; and infection/inflammation control (including infections 

associated with skin around the eye, the corneal surface, or within the ocular 

globe, and the impact of environmental conditions that promote infection). 

• Ocular surface reconstruction and treatment of corneal damage by corneal 

transplantation or through corneal stem cell transplantation. 

• Retinal and optic nerve regeneration (through identification of the genes involved and associated gene therapy, or through other biomedical processes). 

Visual Function/Visual Acuity 

This research relates to the metabolic and physiological processes that relate to 

visual clarity, contrast sensitivity, and spatial orientation. 

• Impact of metabolic modulation or stress on visual acuity and contrast sensitivity (i.e. effect of lowered blood glucose levels on central vision). 

• Visual image processing (better understanding of the biological/electrochemical 

interface in the vision process to improve acuity and advance ‘‘artificial vision’’ 

and other assistive technology). 

• Sensory dysfunction associated with TBI, such as extreme light sensitivity 

(photophobia). 

• Spatial orientation processing (relation of motor control and perception, especially relating to depth perception of objects in a visual field) to enhance peripheral vision. 

• Next-generation refractive error correction and vision augmentation research 

(i.e. LASIK, visual implants/prostheses, and associated corneal healing issues). 

Vision Health Disparities 

This research relates to characterization of visual disparities based upon gender, 

race, or age, and determination of the underlying physiological basis to develop 

treatments and therapies. 

• Epidemiological studies of military populations to determine extent/physiological basis of vision health disparities (i.e. greater incidence of glaucoma, cataracts, and diabetic retinopathy in the African American/Native American/Hispanic populations). 

• Research into low vision caused by traumatic eye injury or chronic eye diseases 

such as age-related macular degeneration or glaucoma. 

• Age-related macular degeneration research (leading cause of blindness in the 

United States and the leading cause of blindness in Americans age 60 and 

over). 

Emerging Adaptive Technology Research 

• Optimal vision rehabilitation management after acute injury, facilitating the 

advancement of evidence-based best practices for blind and low vision rehabilitation. This could become possible by the joint funding of RR&D and HSR&D 

projects that target the development of rigorous, solid best practices guidelines 

with a strong emphasis on vision loss resulting from neuro-trauma. It would 

also address visual impairment concerns of minority veterans, rural veterans, 

and other key target groups. 

• Establishment of a Blind Rehabilitation Service-focused technology evaluation 

and assessment center in conjunction with experienced blind agencies charged 

with identifying the highest quality of vision rehabilitation through independent, scientific testing on both devices and training. Emphasis would be on 

quick, timely turn around of results so veterans can access these newly proven 

adaptive technologies. 


wwoods2 on PRODPC68 with HEARING
42 

*EDITOR’S NOTE: As the conflict in Iraq enters its fourth year, Army ophthalmologists continue treating wounded troops there and in Afghanistan. EyeNet presents the first of two reports 

on the experiences of Eye M.D.s confronting combat-related ocular injuries. NEXT MONTH: Soldiers Journey Home for Recovery. 1www.dior.whs.mil/mmid/casualty/castop.htm. 

2Mader, T. H. et al. Ophthalmology 2006; 113(1):97–104. 

CONCLUSIONS 

Serious combat eye trauma occurring in Operation Iraq Freedom and Operation 

Enduring Freedom has become the third most common injury in both of these conflicts. Only PTSD and TBI are now more common. We urge all members of this Subcommittee to support H.R. 3558, the Military Eye Trauma Treatment Act of 2007. 

The Act creates a Center of Excellence and Eye Trauma Registry. Already having 

included the provisions for the establishment of PTSD and TBI Centers of Excellence in the Wounded Warrior Act, Congress could now, with this critical legislation, 

substantially improve the multidisciplinary coordination, treatment, rehabilitation, 

and research of eye trauma as it relates to TBI. Visually impaired servicemembers 

and veterans within both the DoD and VA systems are depending on passage of this 

bill. We respectfully request that it be passed soon. 

BVA supports specialized, directed research programs in the area of vision that 

will benefit the aging population of blinded and visually impaired veterans. The Association also strongly supports language in the House Armed Services appropriations that includes recommendations for more research for traumatic vision injuries. 

Together with NAEVR’s advocacy, BVA strongly requests that ‘‘Eye and Vision Research’’ maintain its eligibility for funding within the Congressionally Directed Medical Research Program (CDMRP) in FY 2008 Department of Defense (DoD) appropriations. BVA also believes that such funding must be significantly increased from 

the limited $4.8 million appropriated in FY 2007. 

Chairman Michaud and Ranking Member Miller, BVA expresses thanks to both 

of you again for this opportunity to present our testimony. The current need to increase VA research is tremendous when considering the overwhelming numbers of 

veterans suffering from traumatic visual injuries, traumatic brain injury dysfunction, and age-related causes of blindness. The future strength of our Nation depends 

on the willingness of young men and women to serve in our military. This willingness depends, in turn and at least in part, on the willingness of our government 

to meet its full obligation to them as veterans. 

Attachments 

Clinical Update: Cataract 

Wounds of War: Part One: Eye Surgeons in Iraq and Afghanistan 

By Denny Smith, Senior Editor* 

Eyenet Magazine 

May 2006 Edition 

American Academy of Ophthalmology Web Site: www.aao.org 

Original URL: http://www.aao.org/aao/publications/eyenet/200605/comprehensive.cfm 

The cost of war is often counted in fallen soldiers. But war’s survivors, both soldier and civilian, may also pay a tremendous price, by enduring traumatic, disfiguring and life-altering injuries. Ophthalmologists, like many other physicians and 

medical workers, have been tending the wounded in Afghanistan and Iraq for over 

three years now. More than 17,000 American servicemen and women have been 

wounded since the U.S.-led invasions began.1

‘‘The survivors often have very bad injuries, and there’s no way to completely repair many of them,’’ said Thomas H. Mader, MD, a retired U.S. Army colonel who 

served in Iraq in 2004 and who is the primary author of a recent report in Ophthalmology describing ocular and adnexal injuries treated by U.S. Army ophthalmologists.2 ‘‘Occasionally you treat a patient with a relatively minor injury, which can 

be repaired in 10 minutes and the prognosis is excellent. But then there are explosive globe injuries, and other terribly mutilating trauma, where there is absolutely 

no chance at all of salvaging the eye.’’ Dr. Mader is now practicing ophthalmology 

at the Alaska Native Medical Center in Anchorage. 

Eye and brain injuries appear to be more frequent in Afghanistan and Iraq compared with previous U.S. conflicts, even though the number of deaths per injured 

troops has decreased. This apparent spike in head injuries is partly a statistical illusion: The body armor of troops in Iraq and Afghanistan, much improved over what 

soldiers had in World War II, Korea and Vietnam, protects internal organs but not 


wwoods2 on PRODPC68 with HEARING
43 

faces and limbs. So, ironically, doctors now confront profoundly injured troops who 

once would have died of massive thoracic or abdominal wounds before nonfatal injuries to eyes and extremities got medical attention. 

For Every War, a Dread Weapon 

Many of the injuries logged in Iraq result from disastrously effective improvised 

explosive devices (IEDs). These are simple, homemade bombs, such as artillery 

shells filled with glass or rocks, that are detonated remotely as troop convoys pass 

by. The sheer concussive force of IEDs is dangerous in itself, but most injuries are 

related to debris propelled by the blast. ‘‘These fragments can range in size from 

a grain of sand to something the size of your fist,’’ said Dr. Mader. 

Sean M. Blaydon, MD, is a former lieutenant colonel who commanded the Army’s 

first eye surgical team to be deployed in the Iraq conflict, in 2003 and 2004. ‘‘Roadside bombs became more common as the conflict dragged on,’’ said Dr. Blaydon. 

‘‘Many of the injuries were devastating, including large areas of the face or both 

eyes. It’s very troubling to see young kids with both eyes missing. I don’t know anybody who didn’t get personally affected by it.’’ Prior to his service in Iraq, Dr. 

Blaydon was director of ophthalmic plastic, orbital and reconstructive surgery and 

the ocular trauma service at Brooke Army Medical Center in San Antonio. He is 

now a clinical assistant professor at the University of Texas, San Antonio, and in 

private practice in Austin. 

A different, but just as troubling, injury profile was described by Lt. Col. Mark 

F. Torres, MD, who served in Afghanistan in 2003 at Bagram Air Base, north of 

Kabul. ‘‘In Afghanistan there are fewer IED-related injuries and more wounds related to land mines. This is a country with 20 years of recent war, and so there 

are many, many land mines planted throughout the country. Now, thanks to better 

armor, they cause fewer injuries to the thorax or abdomen. But that doesn’t save 

the extremities, head and neck. And the majority of victims are children, who often 

approach the mines out of curiosity, like they would a toy. These typically cause a 

lot of damage to the face and limbs.’’ Dr. Torres is now assistant chief of ophthalmology at Madigan Army Medical Center in Tacoma. 

Care for the Globe 

Physicians witnessing modern warfare are standing at a frontier of visually appalling and medically daunting trauma. But the goal for treating a battle-related 

ocular wound is the same as it would be for any big-city ER trauma: Save the globe 

and preserve vision. 

‘‘We always erred on the side of attempting to preserve badly damaged globes,’’ 

said Dr. Mader. ‘‘Even when it looked like an injury was so severe that the chance 

of the eye’s survival was minimal, we always brought them into the OR and tried 

to do the best repair possible. There are times when an injury is so drastic that you 

just cannot anatomically put the eye back together. When that happens you have 

to know when to call it quits. But we always tried to salvage the eye even if the 

prognosis for useful vision seemed poor.’’ 

Dr. Blaydon concurred. ‘‘The philosophy of my team was to do as much as we 

could to salvage the globe. No matter how severe the injury, if we could put the 

globe together somehow, we did. We knew that in a good 50 percent of severely injured eyes there was little chance that vision was going to be saved, and very likely 

the eyes would eventually be enucleated. But these soldiers were badly injured, and 

sedated, and not able to give consent. If they were enucleated right then, they might 

later second-guess what was done. They may wonder, ‘I came in with 10 other guys 

and maybe they just didn’t have time to save my eye.’ We wanted them to be able, 

later on, to understand how serious the injury was and how every effort was made 

to save the eye. After that, psychologically, they do better if they have an 

enucleation.’’ 

Working shoulder to shoulder. The care given in the first minutes and hours 

after an injury must be intensely organized even in the middle of chaos. Dr. Mader 

described a typical scene. ‘‘Our team worked in Baghdad in the heavily fortified 

Green Zone. We had a general ophthalmologist, an oculoplastics specialist, neurosurgeons and maxillofacial surgeons. We all worked together, often on the same patients, because so many troops with eye injuries had other wounds of the face and 

brain.’’ 

Dr. Blaydon shared a similar picture. ‘‘These soldiers often had multiple injuries. 

On top of a wounded eye, a guy could have had traumatic amputation below the 

knee on one side, lost a foot on the other, and they’re still trying to save one arm. 

Many times we had to delay our surgery because the orthopedic surgeons were trying to save arms and legs.’’ 


wwoods2 on PRODPC68 with HEARING
44 

*At the Joint Meeting in November, Herbert P. Fechter, MD, will moderate a panel of 

military ophthalmologists who will share their experiences in Afghanistan and Iraq. Photos and 

videos will demonstrate the special considerations of ophthalmic war surgery and will address 

a variety of combat-related injuries (Instruction Course #590). 

When assessing a newly injured soldier, Dr. Mader hoped to be able to communicate with him or her. ‘‘Some were unconscious, suffering from horrible head 

wounds. For others, it was helpful if they were still conscious, because you could 

question them, assess their visual loss, ask if they could see light or moving fingers.’’ Sometimes, grimly, the prognosis was obvious, even to the patient. ‘‘One 

young fellow who had lost both eyes in a blast came in fully conscious and was talking clearly to me. He knew what had happened to him.’’ 

Dr. Blaydon described wounds that seemed almost impossible to approach. ‘‘You 

may see ruptured globes in civilian practice, but in combat trauma it could be hard 

even to distinguish pieces of sclera. In everyday urban trauma, a bad rupture is 

usually stellate, with sharp edges, and it’s straightforward to repair. In combat-related, high-velocity injuries, not only do you have complex cornea and sclera lacerations and intraocular contents coming out, but the edges are so necrotic it’s hard 

to even sew them back together.’’ 

Neither bombs nor balm discriminated. Army ophthalmologists have been 

treating soldiers and civilians in almost equal numbers. ‘‘We treated both American 

and allied troops, as well as Afghan military and enemy combatants. The majority 

of casualties we saw were actually Afghan civilians,’’ said Dr. Torres. 

The same was true for Dr. Mader. ‘‘An injured person could randomly be an 

American or an Iraqi, soldier or civilian. When someone was brought into the hospital, we treated everybody the same, whether a civilian, a child or enemy combatant.’’ 

Clinical Update: The Wounds of War: Part Two 

Soldiers Journey Home for Recovery 

By Denny Smith, Senior Editor* 

Eyenet Magazine 

June 2006 Edition 

American Academy of Ophthalmology Web Site: www.aao.org 

Original URL: http://www.aao.org/aao/publications/eyenet/200606/comprehensive.cfm 

Even as the conflicts in Afghanistan and Iraq roll on, wounded servicemen and 

women are returning home with injuries that may require years of medical and psychological rehabilitation. Last month EyeNet featured the experiences of Thomas H. 

Mader, MD, Sean M. Blaydon, MD, and Mark F. Torres, MD, each of whom served 

on Army surgical teams close to combat zones. The soldiers they treated are now 

filling polytrauma facilities in the United States. 

Whisked Away From War 

Troops wounded in Iraq or Afghanistan undergo emergent primary repairs to lifeand sight-threatening injuries often within minutes of sustaining the injury. When 

stable enough, they are transported several times to various levels of care. 

The first stop is Landstuhl Army Medical Center in Germany, then on to Walter 

Reed Army Medical Center in Washington, D.C., or Brooke Army Medical Center 

in San Antonio, and finally on to tertiary-care hospitals around the country. 

These later stages of care can be the hardest part for both doctors and patients. 

‘‘It’s one thing to sew somebody up as best we could do, and it’s another thing to 

provide the follow-up care,’’ said Dr. Mader. ‘‘That is a very, very difficult job, both 

professionally and emotionally. As you can imagine, the psychological impact of a 

young man losing one or both eyes has to be dealt with by both patient and physician.’’ 

Physicians and families take a long view. The community ophthalmologist 

may be seeing more such veterans, and they will need multiple levels of care for 

many years, according to Glenn C. Cockerham, MD, chief of ophthalmology at the 

VA Palo Alto Health Care System and clinical associate professor of ophthalmology 

at Stanford University. 

‘‘When they come to us they are entering a period in which late complications, 

including retinal detachments, corneal decompensation, traumatic cataracts or posterior capsular opacifications, may present,’’ said Dr. Cockerham. ‘‘If one eye, usually on the side of the blast, is severely damaged, it is extremely important to take 

special care of their better-seeing eye. But many of them have head injuries and 


wwoods2 on PRODPC68 with HEARING
45 

1Mader, T. H. et al. Ophthalmology 2006;113(1):97–104. 2Gawande, A. N Engl J Med 2004;351(24):2471–2475. 

resulting memory problems, so we include families in the rehabilitation process to 

watch over their loved one and make sure they get to appointments. Their families 

are usually very supportive, having been there for them throughout.’’ 

Collaborative care is key. Dr. Torres explained how the community ophthalmologist can offer veterans care. ‘‘There are a lot of joint arrangements between 

military hospitals and the VA, and between the VA and civilian academic medical 

centers. The average comprehensive ophthalmologist offering long-term management of a combat-related trauma should, pretty easily, be able to consult with combat-experienced ophthalmologists.’’ 

Dr. Blaydon agreed. ‘‘The general ophthalmologists can manage these returning 

vets, but they might be seeing a different trauma than they would in an emergency 

room. Much of it is explosive, high-velocity, blunt trauma to the face, which means 

there’s a lot of soft-tissue damage and underlying skeletal damage. Many had globe 

ruptures that were severe and complex, and there are often fine, foreign bodies embedded in the cornea. Even if the rupture is repaired perfectly, the patient remains 

corneally blind. Many of these will go on to corneal transplant. Some of them have 

bad retinal injuries from just blunt trauma.’’ 

Courage and Candor Beyond the War 

Most returning veterans are very young, between their late teens and early 

twenties. Dr. Blaydon maintains a deep regard for their emotional well-being. ‘‘I am 

in awe of the attitude and the motivation of these young guys. Before you address 

their specific injury, it’s important to consider the psychology of the veteran. They 

went over there to serve their country and to serve alongside their comrades, and 

they want us to respect the fact that they were doing their job when they got their 

injury. These patients need a lot of physical and emotional therapy to get back into 

society.’’ 

Americans are deeply divided over the Iraq conflict. And yet, Dr. Blaydon has observed that the soldiers are coming home to a country that cares for them. ‘‘This 

war is as divisive as any we’ve had in the past. The difference now is that returning 

vets are receiving support from both sides of the fence. That’s an important part 

of welcoming these soldiers home.’’ 

Hope for vision preempted. Conceivably, some of these soldiers could benefit 

from research into artificial retinas, research that has received significant funding 

from the Department of Energy. But Dr. Blaydon said the devastating nature of 

many injuries means that few of these veterans would be good artificial retina candidates. ‘‘The anterior visual camera, the optic nerve and visual pathway must all 

be intact for an artificial retina to be considered.’’ These crucial structures are obliterated in many vets. 

Precautions slow to appear. One of the questions now haunting the military 

is whether U.S. troops were provided adequate protection for battle. Since the Afghanistan and Iraq conflicts began, Army ophthalmologists have repeatedly asked 

for troops to be given better eyewear. While no form of protection can eliminate all 

injuries, many could have been prevented or lessened in severity. In fact, Dr. Mader 

writes in Ophthalmology, ‘‘Polycarbonate ballistic eyewear could have prevented 

many, but not all of the ocular injuries we report.’’ 1

Dr. Blaydon noted that ophthalmologists had long lobbied the Army for the type 

of ballistic eyewear that protects against low-velocity projectiles. The Army had developed eye armor known as Ballistic/Laser Protective Spectacles, but almost none 

of the soldiers had them. ‘‘The Army, as far as we could tell, did not issue them. 

Eye armor just was not part of the issue,’’ Dr. Blaydon said. 

The Army did issue Sun, Wind and Dust Goggles, which can protect the eye 

against some minor injuries. But they are cumbersome, and can often impair clear, 

full peripheral vision. ‘‘Soldiers just do not like to wear them. What they do like to 

wear are Wiley X ballistic goggles that fit closely to the face. But the soldiers had 

to purchase these on their own. The Army soon realized how severe and frequent 

the eye injuries were and began purchasing these goggles and mandating that they 

be worn,’’ Dr. Blaydon said. Even these goggles cannot protect against the most potent improvised explosive devices, but, he noted, ‘‘The incidence of injuries has since 

gone down, depending on the tempo of operations.’’ 2

From a distance. These physicians tend to deflect credit for their own heroic 

service into recognition of others still working in the combat zones. ‘‘Many soldiers 

would have died had it not been for the premier care they got in Baghdad. The surgeons there are the top-of-the-line and that care is as good as you’re going to get 

in a critical care hospital,’’ said Dr. Blaydon. 


wwoods2 on PRODPC68 with HEARING
46 

Dr. Mader regards his experience with equanimity. ‘‘If there was any positive 

thing about being there, I would say I worked with some of the finest young people 

I’ve ever met in my life. Had I been wounded and brought to that 31st Combat Support Hospital, I would have had complete faith in the medical personnel working 

there.’’ 

Dr. Torres shared a similar sentiment. ‘‘It’s a rewarding experience in unfortunate 

circumstances. You feel like you’re doing something positive, even if the world 

around you is not.’’ 

f 

Prepared Statement of Carl Blake 

National Legislative Director, Paralyzed Veterans of America 

Mr. Chairman and members of the Subcommittee, Paralyzed Veterans of America 

(PVA) would like to thank you for the opportunity to testify today on the research 

programs conducted by the Department of Veterans Affairs (VA). Research is a vital 

part of veterans’ health care, and an essential mission for our National health care 

system. PVA is very involved in many aspects of medical and prosthetic research 

because of the long-term impact that these initiatives can have on our members. 

The VA health care system is a unique environment combining clinical care, education, and research. VA currently supports approximately 3,800 researchers at 115 

VA medical centers. The research program serves as an excellent recruitment tool 

for young doctors as well as scientists because it gives them an opportunity to develop skills as clinical researchers. According to the VA, nearly 83 percent of VA 

researchers are practicing physicians. Because of this dual role, VA research often 

immediately benefits patients. For example, functional electrical stimulation, a technology using controlled electrical currents to activate paralyzed muscles, is being developed at VA clinical facilities and laboratories throughout the country. This technology is now being applied to many PVA members receiving health care service 

and rehabilitation therapy at spinal cord injury centers. Through this technology, 

tetraplegic patients have been able to grasp objects, stand and pivot to assist transfers, and control bladder function. We anticipate greater capacity for even walking 

short distances. 

PVA interacts a great deal with the VA’s Office of Research and Development. 

Most of our attention is focused on the Rehabilitation Research and Development 

(RR&D) and Health Services Research and Development Service (HSR&D). RR&D 

projects involve technologies such as wheelchair development and testing, seating 

systems, functional electrical stimulation (FES), audiology, prosthetics and orthotics, 

and other components. HSR&D projects are multidisciplinary activities that involve 

expertise in a combination of clinical fields—physicians, nurses, therapists—as well 

as social sciences—psychology, sociology. It involves delivery system research and 

application. This particularly involves the Quality Enhance Research Initiative 

(QUERI), which includes spinal cord injury (SCI). PVA’s Research Department has 

been a direct participant in the QUERI executive group as well as the SCI QUERI 

since their inception. 

Meanwhile, the Clinical Sciences Research and Development Service (CSR&D) 

conducts clinical trials and epidemiological research on key diseases that impact veterans. CSR&D research project accomplishments include key research findings 

across a range of diseases and definitive evidence for clinical practice. 

Through the system’s scope of primary, secondary, and tertiary care, as well as 

long-term care, with multi-disciplinary academic affiliations, the VA brings validation and innovation to the delivery of the best care for today’s veterans. Perfect examples of this idea are the Parkinson’s Disease Research Education and Clinical 

Centers (PADRECC) and Multiple Sclerosis (MS) Centers of Excellence. These centers represent a successful strategy to focus the Veterans Health Administration’s 

(VHA) system-wide service and research expertise to address two critical care segments of the veteran population. They integrate direct health care services, education, and research to the benefit of veterans in the system. 

In testimony during the 109th Congress, PVA supported legislation that would 

create Amputation and Prosthetic Rehabilitation Centers of Excellence (similar to 

those for MS and Parkison’s disease). The need for these centers is amplified by the 

number of veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who have amputations. As we stated with regards to the Parkinson’s disease and MS Centers of Excellence, the VA has the essential expertise to focus dedicated services on a wide range of medical conditions. It then transfers learned approaches for specific care to the broader VA health care system. However, the Veterans Health Administration (VHA) often times lacks the financial wherewithal to 


wwoods2 on PRODPC68 with HEARING
47 

create a needed focal point or center. This legislation calls for the creation of these 

focal points and the need for resources to actuate that goal. We must emphasize, 

however, that additional real dollars will likely be needed to establish these centers. 

Furthermore, these centers could partner with the new Amputation and Prosthetic clinic recently opened at Walter Reed Army Medical Center. This partnership 

could enhance the long-term provision of these services to veterans as it would allow 

the VA to remain on the cutting edge of amputation and prosthetic research in conjunction with DoD. This is particularly important as the VA will likely be responsible for caring for the men and women with prosthetic needs over the course of 

their lives. 

Additionally, VHA should be required to partner with manufacturers, dealers, 

payers, and advocates to develop performance test standards for amputee and prosthetic devices. An example of these types of test standards is the American National 

Standards Institute (ANSI) and Rehabilitation Engineering and Assistive Technology Society of North American (RESNA) Wheelchair Performance Standards. 

These standards are a collaborative effort with specific impacts on wheelchair research and development, consumer disclosure, and payer decisions. PVA believes 

that these centers could be the spearhead for development of evidence-based performance test standards for amputee and prosthetic devices. Furthermore, expertise 

on these matters could be drawn from such projects as the VA’s Human Engineering 

Research Laboratories (HERL), a project being conducted in collaboration with the 

University of Pittsburg and supported by PVA’s Research Foundation, and focused 

on mobility technologies. 

PVA has a particular interest in research projects that the VA administers as it 

continues to address neurotrauma and sensory loss, primarily as a result of spinal 

cord injury or disease (SCI/D) or traumatic brain injury (TBI). As you are well 

aware, traumatic brain injury is recognized as the signature injury of combat in 

Iraq and Afghanistan. According to the VA’s estimates, TBI and various degrees of 

SCI account for nearly 25 percent of the combat casualties sustained by servicemembers in OIF/OEF. Despite the positive gains by advancements in body armor, 

the head (and by extension the brain), as well as the cervical spine, are exposed to 

significantly more trauma. This has not only lead to specific injuries related to TBI 

and paralysis, but also vision loss, psychological problems, and the larger 

polytrauma aspect. 

As such, it is absolutely essential that continued research in the areas of TBI and 

SCI continue to advance. PVA has long been a leader in the field of spinal cord research. Through the PVA Research Foundation, we continue to work to find a cure 

for SCI/D and alleviate the effects of similar conditions. Through the PVA Education 

Foundation, we develop tools to share the broad-based knowledge for SCI/D care 

with all types of health care professionals. Finally, PVA, as a partner in the Consortium for Spinal Cord Medicine, promotes the use of evidence-based clinical practice 

guidelines and consumer guides. PVA also supports numerous efforts in the field. 

For example, at the Center for Neuroscience and Regeneration Research at Yale 

University, scientists study nerve regeneration that may ultimately lead to better 

treatments for SCI or possibly even a cure. This work is conducted in conjunction 

with the VA. 

Likewise, PVA believes more research must be conducted to evaluate the symptoms and treatment methods of veterans who have experienced TBI. This is essential to allow VA to deal with both the medical and mental health aspects of TBI, 

including research into the long term consequences of mild TBI in OEF/OIF veterans. Furthermore, TBI symptoms and treatments can be better assessed for previous generations of veterans who have experienced similar injuries. 

PVA also supports a couple of specific research projects that the VA instituted 

during FY 2007. The first project focuses on the special needs of service personnel 

returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom 

(OEF). The project will develop new treatments and tools for clinicians to ease the 

physical and psychological pain of men and women returning from the combat theaters, improve access to VA healthcare services, and accelerate discoveries and applications, especially for neurotrauma, sensory loss, amputation, polytrauma, and related prosthetic needs. We appreciate that even as the VA begins to move forward 

with this project, it is already collecting data to determine if the health care needs 

of amputees and severely injured veterans from OIF and OEF are being met and 

to identify areas where improvement is needed. These data will help focus the 

project on additional areas that need to be studied. 

This project directly supports the important role that research plays in the clinical 

setting. Through this project clinicians can learn and apply new tools to the treatment of physical and psychological conditions experienced by the men and women 

returning from the Global War on Terror. Furthermore, findings from this research 


wwoods2 on PRODPC68 with HEARING
48 

project can be shared with Department of Defense (DoD) treatment facilities, particularly Walter Reed Army Medical Center and Brook Army Medical Center, as 

well as the Defense Advanced Research Projects Agency. This collaboration will be 

absolutely essential as it will provide for new screening tools, clinical applications, 

and long-term follow-up. 

As a member of the Friends of VA Research (FOVA) coalition, we wholeheartedly 

support the vision to expand the VA research program to encompass the needs of 

service personnel returning from current conflicts, whether they include polytrauma, 

massive burn injury, or mental health conditions. Such expansion of the program 

requires new resources so that VA’s other research areas, which are equally important to the long-term care of veterans, do not suffer. 

The second special research project focuses on genomic medicine. The thrust of 

this project is to link veterans’ genetic information with the VA electronic health 

record. The program will ultimately allow clinicians to make better decisions for veterans based on their genetic information. Furthermore, it will address patients’ 

rights, informed consent, privacy, and ownership of genetic material involved with 

genetic tissue banking. We believe that the human genome reports of recent years 

have provided a strategy to integrate clinical symptomology with genetic testing to 

create a predictive model that could extend health care delivery to a truly preventive service. 

However, despite the expectations of this exciting field, we must reiterate that additional new funding will be necessary. Genomic medicine cannot be advanced by 

simply reshuffling funding priorities within existing VHA R&D funding. If it is 

placed into a stream where it will compete with current VA projects, the sheer scope 

and cost of genomic medicine will overrun all other ongoing projects. This will simply not be a cheap field to study, so the burden should be shared by the Veterans 

Health Administration (VHA) and DoD. Moreover, the genomic priorities of NIH 

should be marshaled with VHA. 

PVA also believes that one particular change should be made that would allow 

the VA to invest additional resources into its infrastructure. Currently, many VA 

researchers are primary grantees from the National Institutes of Health (NIH). 

However, these researchers do not receive any funding to support management and 

physical plant costs of their projects. Their physical infrastructure and administrative costs (also called indirect costs), which are vital to the support of the research 

enterprise, are not funded by NIH to VA researchers. However, if that same VA researcher carries that same grant through an academic affiliate, then NIH would 

provide full indirect support. If the VA is going to attract clinician researchers, they 

must provide the best environment; otherwise, they are placed at a significant competitive disadvantage. Simply put, Congress must provide funding for capital improvement and support the VA research enterprise or NIH should be required to 

pay fair indirect costs to the VA. 

Finally, I must emphasize our concern about funding for the overall Medical and 

Prosthetic Research program. We certainly appreciate the fact that the appropriations bills passed by the House and Senate meet or exceed the $480 million that 

The Independent Budget calls for in FY 2008. However, with the outcome of the appropriations still hanging in limbo, and the fact that no appropriation has been provided even as the start of the new fiscal year has passed, we remain concerned 

about the ongoing viability of the VA research program. It is time to put the games 

aside and complete the appropriations work that these programs so vitally rely 

upon. 

Mr. Chairman, PVA appreciates your continued interest in maintaining a viable 

research program. We look forward to working with the Subcommittee to ensure 

that adequate resources are provided for Medical and Prosthetic Research. Quality 

research outcomes can only lead to better patient care for veterans. 

Thank you again. I would be happy to answer any questions that you might have. 

f 

Prepared Statement of Joy J. Ilem 

Assistant National Legislative Director, Disabled American Veterans 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV) to provide testimony on Department of Veterans Affairs (VA) research programs. As an organization of more than one million service-disabled veterans, DAV has a genuine concern 

about the health and well-being of the men and women who are serving today or 

who have served our country and suffered physical and mental disabilities as a result of military service. 


wwoods2 on PRODPC68 with HEARING
49 

VA’s research program, developed following World War II, has a rich and robust 

history with a clear mission, ‘‘To discover knowledge and create innovations that advance the health and care of veterans and the nation.’’ The program is distinguished 

by three Nobel Laureates, six Lasker Prize winners, and a number of important discoveries and inventions. Today, VA’s offices of Health Services Research and Development and Rehabilitation Research and Development are focusing on a number of 

important areas including: posttraumatic stress disorder (PTSD); mental health and 

substance abuse; spinal cord injury; genomic medicine; and women’s health. The 

complex and unique injuries sustained by troops serving in Iraq and Afghanistan 

have created the need for new research and treatment strategies focused on addressing the unique needs of the newest generation of combat disabled veterans who 

have traumatic brain injury (TBI); polytrauma; spinal cord injury; burns; amputations; and hearing and vision loss. Although VA has been the leader in conducting 

research on many war-related injuries in the past, it is critically important that 

proper funding be made available for VA to expeditiously conduct research and effectively implement related advances in treatment for all of these devastating injuries. My testimony will focus on several of these areas in more detail. 

Prosthetics 

Many veterans who served in Operations Enduring and Iraqi Freedom (OEF/OIF) 

have sustained catastrophic or polytraumatic injuries during their military service 

to include severe brain injury, spinal cord injury and traumatic amputation. Most 

servicemembers begin the recovery and rehabilitation process at Walter Reed Army 

Medical Center (WRAMC) or other specialty military treatment facilities. ‘‘Warrior 

Rehab’’ as it is known is an extraordinary example of the incredible journey many 

severely injured veterans travel as they are rehabilitated, fitted and trained to use 

state-of-the-art prosthetics. The new rehabilitation center at WRAMC and the extraordinary Center for the Intrepid (which was sponsored by DAV and our contributors), are two of the world’s most technologically advanced rehabilitation centers for 

amputees. As servicemembers transition to veteran status and into VA care, we encourage VA to significantly increase research on amputation, prosthetics, and 

orthotics to help improve health outcomes and make available the newest technologies for this unique patient population. A significant number of servicemembers 

and veterans returning from OEF/OIF today are young—and aggressive rehabilitation programs are helping them return to very active lifestyles. VA will be responsible for the long-term health maintenance of this population for decades; therefore, 

it is appropriate that VA develop research initiatives that ensure VA is the leader 

in advancing new technologies and prosthetic and orthotic items, and rehabilitation 

models that promote good health outcomes for veterans with amputations. Any research should also include older veterans from previous generations who could benefit from these studies. 

Traumatic Brain Injury 

Mr. Chairman, Traumatic Brain Injury (TBI) and spinal cord injury account for 

almost 25% of the combat casualties sustained by our soldiers in OEF/OIF. Blast 

injuries that violently shake or compress the brain within the closed skull cause 

devastating and often permanent damage to the brain—and veterans with severe 

TBI will likely need a lifetime of care for their injuries. 

Military service personnel who sustain catastrophic physical injuries, and suffer 

severe TBI, are easily recognized and the treatment regimen is well-established. 

However, VA experts note that TBI can also be caused without any apparent physical injuries when a veteran is in the near vicinity of improvised explosive device 

(IED) detonation. Veterans suffering a milder form of TBI may not be detected so 

readily, but symptoms can include chronic headaches; irritability; disinhibition sleep 

disorders; confusion; memory problems; and depression. With nearly 15,000 IEDs 

now reported in Iraq alone, it is believed that many OEF/OIF servicemembers have 

suffered mild brain injuries or concussions that have gone undiagnosed, and that 

symptoms may only be detected later, when these veterans return home. 

We are concerned about emerging literature that strongly suggests that even 

‘‘mild’’ TBI patients may have long-term mental health and other health consequences. According to VA’s mental health experts, mild TBI can produce behavioral manifestations that mimic PTSD or other symptoms. TBI and PTSD can also 

be co-existing conditions. Much is still unknown about the long-term impact of these 

injuries and the best treatment for mild/moderate TBI. The influx of OEF/OIF servicemembers returning with brain injury and trauma has increased opportunities for 

research into the evaluation and treatment of such injuries in newer veterans; however, we suggest that any studies undertaken by VA include older veterans of past 

military conflicts who may have suffered similar injuries that thus far have gone 


wwoods2 on PRODPC68 with HEARING
50 

undetected, undiagnosed, and untreated. Their experiences could be of enormous 

value to researchers interested in the progression of these injuries on a long-term 

basis. Likewise, such knowledge of historic experience could help both Department 

of Defense (DoD) and VA better understand the procedures and policies needed to 

improve screening, diagnosis and treatment of mild TBI in the newest generation 

of combat veterans. 

We are pleased that VA has designated TBI as one of its special emphasis programs, and is committed to working with DoD to provide comprehensive acute and 

long-term rehabilitative care for veterans with brain injuries. We urge Congress to 

remain vigilant to ensure that VA research programs are sufficiently funded and are 

adapted to meet the unique needs of the newest generation of combat service personnel and veterans with TBI, while they continue to address the needs of older veterans with severe physical disabilities, as well as posttraumatic stress disorder 

(PTSD) and other combat-related mental health challenges. 

Mental Health 

Current research findings indicate that OEF/OIF combat veterans are at higher 

risk for PTSD and other mental health problems caused by their experiences and 

exposure in these wars. 

VA reports that veterans of these current wars have sought care for a wide range 

of possible medical and psychological conditions, including mental health conditions, 

such as adjustment disorder, anxiety, depression, PTSD, and the effects of substance 

abuse. Through July 2007, VA reported that of the 252,095 separated OEF/OIF veterans who have sought VA health care since fiscal year 2002, a total of 94,921 

unique patients had received a diagnosis of a possible mental health disorder. Over 

45,000 of the enrolled OEF/OIF veterans had a probable diagnosis of PTSD, and almost 38,000 reported nondependent abuse of drugs. Also, critically, 31,000 OEF/OIF 

veterans have been diagnosed with depression. 

In a recent study, VA New Jersey-based researchers examined substance abuse 

and mental health problems in returning veterans of the war in Iraq. Researchers 

noted that although increasing attention is being paid to combat stress disorders in 

veterans of the Iraq and Afghanistan conflicts, there has been little systemic focus 

on substance abuse problems in this cohort. In the group studied (292 New Jersey 

National Guard members who had returned from Iraq within the past 12 months) 

there was a 39.4 percent prevalence of a substance abuse problem; 37.1 percent reported problem drinking; and a 21.2 percent prevalence of alcohol abuse or dependence. Highlights of the study included the following findings: nearly 47 percent of 

veterans studied had reported a mental health and/or substance abuse problem. 

Substance use problems were found to be higher among veterans with mental 

health problems; access to treatment both during and after deployment was especially low for those needing substance abuse treatment (among veterans with dual 

disorders—41 percent received mental health treatment but only 9 percent received 

treatment for substance abuse). We urge VA to continue research into this critical 

area and to identify the best treatment strategies to address substance abuse and 

other mental health and readjustment issues collectively. 

We urge VA to continue research that is veteran-centered and specifically focused 

on rehabilitation of veterans with physical and cognitive impairments related to 

military service and studies to identify and promote effective and efficient strategies 

to improve the delivery of healthcare to veterans. We believe VA’s research priorities should include: 

• A study to objectively and systematically measure the expectations of OEF/OIF 

veterans to help VA better serve this population. These veterans are younger, 

have family and community support systems in place, and are frequently dealing with complicated post-service readjustment, employment, education and 

other issues. VA should conduct health services and other research to identify 

services to meet their mental health needs. 

• Studies to address access issues for this new population including tracking of 

OEF/OIF veterans to learn what services they utilize. VA should also examine 

barriers to care, especially those that relate to attitudes of veterans and their 

families toward being treated in the VA, and any breakdown in access this may 

cause. 

The DoD and VA share a unique obligation to meet the health care—including 

mental health care—and rehabilitation needs of veterans who are suffering from readjustment difficulties and various injuries as a result of combat service. Both agencies need to ensure that appropriate research is conducted and that federal mental 

health programs are adapted to meet the unique needs of the newest generation of 

combat service personnel and veterans, while continuing to address the needs of 


wwoods2 on PRODPC68 with HEARING
51 

older veterans with substance abuse problems, PTSD and other combat-related readjustment issues and other mental health challenges. Congress must remain vigilant to ensure that research and treatment programs are authorized and sufficiently 

funded. 

Women Veterans 

With increasing numbers of women serving in the military, and with more women 

veterans seeking VA health care following military service, it is essential that the 

VA be responsive to the unique demographics of this veteran population cohort. In 

addition, VA must ensure that its special rehabilitation programs are tailored to 

meet the unique health concerns of women who have served in combat theaters and 

those who have suffered catastrophic disabilities as a result of military service. 

Women’s health research is essential to achieving these objectives—specifically to 

fully understand the healthcare needs of this population and to develop high quality 

services and treatments. 

In 2004, VHA’s Office of Research and Development held a groundbreaking conference, ‘‘Toward a VA Women’s Health Research Agenda: Setting Evidence-Based 

Research Priorities for Improving the Health and Care of Women Veterans.’’ The 

participants of the conference were tasked with identifying gaps in understanding 

women veterans’ health and health care, and with identifying the research priorities 

and infrastructure required to fill these gaps. In April 2005, a special solicitation 

was issued for intramural VA research proposals to assess health care needs of 

women veterans and demands on the VA health care system in targeted areas, such 

as mental health and combat stress, military sexual trauma (MST), PTSD, homeless 

women veterans, and differences in era of service (e.g., Iraq vs. Gulf War service 

periods). An entire issue of the Journal of General Internal Medicine was dedicated 

to VA research and women’s health in March 2006. Published findings included articles on why women veterans choose VA health care; barriers to VA health care for 

women veterans; the health status of women veterans; PTSD and increased use in 

certain VA medical care services; and MST. 

We have strongly encouraged VA, as it takes steps to advance this agenda, to 

focus on research and programs that enhance VA’s understanding of women veterans’ health issues and discover new ways to optimize health care delivery and improve health outcomes for this special VA patient population. 

Mr. Chairman, one area of particular interest to DAV is the incidental impact of 

VA’s primary care model on women’s health. There has been a trend in the Veterans 

Health Administration (VHA) to move away from dedicated women’s health clinics, 

to general primary care, for the purpose of providing both primary and gender-specific health care to women veterans within unified clinics. According to VA, less 

than half of its facilities surveyed provide care to women through mixed gender primary care teams, referring women to specialized women’s health clinics for genderspecific care. In the mid-1990s, VA reorganized from a predominantly hospital-based 

delivery care model, to an outpatient health care delivery model, focused on preventative and health maintenance care. While we believe that shift was appropriate, we 

are concerned about the incidental impact of the primary care model on the quality 

of health care delivered to women. VA’s 2000 conference report, ‘‘The Health Status 

of Women Veterans Using Department of Veterans Affairs’ Ambulatory Care Services,’’ noted that with the advent of primary care in VA, many women’s clinics were 

being dismantled and that women veterans were assigned to primary care teams on 

a rotating basis, without regard to gender. Findings from that report indicated that 

this practice further reduced the ratio of women to men in any one practitioner’s 

caseload, making it increasingly unlikely that an individual clinician would gain the 

clinical exposure necessary to develop and maintain expertise in women veterans’ 

health. We understand that a follow-up study is currently being conducted and that 

VA researchers will study the impact of the practice structure on the quality of care 

for women veterans, and the fragmentation of care including unmet health care 

needs of those with chronic physical and mental health conditions. 

VA acknowledges that full-service women’s primary care clinics that provide comprehensive care, including gender-specific care, are the optimal milieu for providing 

care to women veterans. Or, in cases where there are relatively low numbers of 

women being treated at a given facility, it is preferable to assign all women to one 

primary care team, or provider, in order to facilitate the development and maintenance of provider clinical skills in women’s health. VA also notes that the health 

care environment directly affects the quality of care provided to women veterans 

and has a significant impact on a patient’s comfort, privacy, feeling of safety, and 

sense of welcome. 

According to VA researchers, although women veterans surveyed reported that 

they prefer receiving primary and gender-specific health care from the same proVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00055 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
52 

vider or clinic, in actuality, their care is often fragmented, with different components of care being provided by different clinicians with variable degrees of coordination and expertise in caring for women. Additionally, researchers have found a 

number of barriers to delivering high quality health care to women veterans. Specifically, insufficient funding for women’s health programs; competing local or network priorities; limited resources for outreach; inability to recruit specialists; lower 

numbers of women veterans’ caseloads; limited availability of after-hours emergency 

health services; and an insufficient number of clinicians skilled in women’s health, 

have been identified as current barriers to care for women veterans. 

VA Researchers made several recommendations to address these barriers, including concentrating women’s primary care delivery to designated providers with women’s health expertise within primary care or women’s health clinics; enhancing provider skills in women’s health; providing telemedicine-based access to experts to aid 

in emergency health care decisionmaking; and increasing communication and coordination of care for women veterans using fee-basis or contract care services. We urge 

this Subcommittee to provide oversight and to monitor VA’s progress in this area. 

We also encourage VA to continue to make women’s health a research priority and 

to develop new knowledge about how to best provide for the health and care of 

women veterans. 

Addressing the Needs of Women Veterans Who Served in OEF/OIF 

The challenge of addressing the health care needs of the growing number of 

women veterans exposed to combat with and without obvious injury is daunting. In 

the future, the needs will likely be significantly greater with more women seeking 

access to care, increased health care utilization, and a more diverse range of medical 

conditions. It is unlikely the past experience of women veterans in the VA will serve 

as an accurate guide because of the unique experiences and exposures of women veterans who served in OEF/OIF. 

Given the increasing role of women in combat deployments, and with more than 

70,000 women now having served in the OEF/OIF combat theaters, we are pleased 

that the Women’s Health Science Division of VA’s National Center for PTSD (hereinafter Center) is evaluating the health impact of combat service on women veterans, including the dual burden of exposure to traumatic events in the combat theater and the potential of MST. According to the Center, although there is no current 

empirical data to verify MST is occurring in Iraq at a higher rate than expected, 

there have been numerous reports in the popular press citing cases of sexual misconduct in theater. In the Center’s Women’s Stress Disorder Treatment Team, of 49 

returning female veterans, 20 (41 percent) reported MST. This is very disturbing to 

DAV and we believe it warrants greater attention by VA in its research portfolio. 

Additionally, the Center notes that anecdotal reports from OEF/OIF veterans suggest a number of unique concerns that have a more direct impact on women than 

on their male counterparts returning from combat theaters, including lack of privacy 

in living conditions; sleeping and showering areas; limited gynecological healthcare 

in theater; healthcare impact of women choosing to stop their menstrual cycle; and 

health consequences of dehydration and chronic urinary tract infection. Findings 

also suggest distinct differences occur in homecoming, including that women may 

be less likely to have their military service recognized or appreciated by their communities; possible differential access to VA treatment services; and increased parenting and financial stress that they must endure. 

DAV is pleased that the Center is examining gender differences in mental health; 

MST in the combat theater; gender differences and other stressors associated with 

OEF/OIF service and homecoming, including treatment of PTSD in women; enhancing sensitivity toward, and knowledge of, women veterans and their healthcare 

needs among VA staff; and MST among reserve components of the armed services. 

We also understand a number of VA research projects are focused on evaluation 

of the VA’s MST screening and treatment programs including identifying the prevalence of MST and the associated mental and physical health conditions (especially 

among all VA users and OEF/OIF veterans), establishing the association between 

MST screening and later use of MST-related treatments, and identifying key characteristics of VA facilities that influence successful implementation of MST screening 

and treatment practices. 

Some women suffer from severe PTSD and will require intensive evidence-based 

treatment. VA has conducted ground-breaking research on evidence-based treatment 

for PTSD, including a recent study that established its efficacy for women. While 

these developments are an important first step, they will only have an impact on 

the thousands of women veterans affected when these techniques are fully deployed 

throughout the VA system and easily accessible to providers and patients. This is 

not currently the case, as acknowledged by the National Center representative in 


wwoods2 on PRODPC68 with HEARING
53 

recent testimony before the President’s Commission on Care for America’s Returning Wounded Warriors. 

We acknowledge that VA is attempting to address the needs of women veterans 

returning from combat theaters in a variety of ways, and has provided guidance for 

medical facilities to evaluate the adequacy of programs and services for returning 

OEF/OIF women veterans in anticipation of gender-specific health issues. However, 

additional research including improvement in sharing data and health information 

between DoD and VA is essential to understanding and best addressing the health 

concerns of women veterans. At this time we do not fully understand the barriers 

that may prevent OEF/OIF women from accessing VA care. We do know from recent 

studies of OEF/OIF active duty and reserve component personnel that stigma is a 

major barrier in accessing mental health services; with over 40% reporting that stigma would impact their decision to seek care. We believe further research is necessary that looks at the barriers that women veterans perceive or have experienced 

in seeking VA health care. 

VA needs to ensure priority is given to women veterans’ programs so quality 

health care and specialized services are made available equally for women and men. 

VA must continue to work to provide an appropriate clinical environment for treatment, even where there is a disparity. Given the changing roles of women in the 

military, VA must also be prepared to anticipate the specialized needs of women 

veterans who were sexually assaulted in military service and/or catastrophically 

wounded in combat theaters. Although it is anticipated that many of the health 

problems of male and female veterans returning from combat operations will be 

similar, VA facilities must address the health issues that pose special challenges for 

women. DAV has recommended that VA focus its women’s health research on finding the health care delivery model that demonstrates the best clinical outcomes for 

women veterans. Likewise, VA should develop a strategic plan, in conjunction with 

DoD, to collect critical information about the health status and continuing care 

needs of women veterans with a focus on evidence-based practices to identify other 

strategic priorities for a woman’s health research agenda. 

DAV makes the following research recommendations to better serve women veterans returning from combat theaters. 

• VA should conduct research involving recently discharged active duty women 

and recently demobilized female Reserve component members to assess the barriers that they perceive, or have experienced, to seeking health care through 

VA. Research should include assessments of the effect of stigma, driving distance to the nearest source of care, lack of child care, understanding of VA eligibility and services, user friendliness of VA services for those who have attempted to access care, cultural sensitivities that differentially affect women, 

and other key potential barriers. 

• VA should quickly disseminate and deploy resources to make evidence-based 

PTSD treatment easily accessible for women veterans across the country, and 

explore options for providing child care for those needing it to enable them to 

achieve access to treatment. 

• DoD should fund a prospective, population-based health study of women who 

served in OEF/OIF. An epidemiologic study with at least a 10-year follow-up period is needed. This study should be carried out by DoD, VA, and University 

researchers collaboratively. 

• VA should conduct a comprehensive assessment of its Women Veterans’ Health 

Programs, including specialized programs for women who are homeless or have 

substance-use and/or mental health challenges, and develop an action plan to 

improve services for this population and projected future needs of OEF/OIF 

women veterans. 

• VA should conduct research to fully understand the dual burden of military sexual trauma and combat-related PTSD, and develop the best treatment practices 

and programs for this population. 

Other areas relevant to MST that could benefit from additional research resources: 

• Expand evidence-based treatment for mental health conditions associated with 

MST, beyond PTSD (e.g., depression, substance abuse, eating disorders, and difficulties with sexual functioning). 

• Increase research into the physical health co-morbidities associated with MST 

and how to more effectively work with MST and veterans in the primary care 

setting. 

• Focus on ways in which existing MST treatments can be adapted to for men 

(In general, men are an understudied population when it comes to MST.) 


wwoods2 on PRODPC68 with HEARING
54 

• More research into barriers both male and female veterans face when trying to 

access MST-related treatment services. • Research into the prevalence and consequences of MST during OEF/OIF combat 

deployments. • Greater understanding of the phenomenology and dimensions of MST within VA 

(e.g., what specific harassment and assault experiences are captured by the existing MST screening mechanism.) • Program evaluation research focused on demonstrating the effectiveness of innovative treatment programs prior to exporting the programs to additional facilities and programs. 

Aging Veteran Population 

While additional research and resources must be provided to better treat our newest generation of combat veterans, VA stills has a large cohort of aging veterans 

who served in earlier periods. In that respect, research focused on diabetes, hypertension, heart disease and other chronic illnesses affecting older populations must 

continue. Also, we are concerned that VA research address the needs of elderly veterans with co-morbid mental health and substance-use disorder problems. 

DAV recommends that VA consider research for this population that: 

• Addresses the health care needs of aging veterans with traumatic injuries (spinal cord injury, amputations, sensory loss), who now also must cope with the 

diseases of old age (such as heart disease, diabetes, chronic obstructive pulmonary disease, hypertension, etc.). Clinicians report they are seeing Vietnam 

veteran population cohorts who are already beginning to experience these problems; 

• Develops innovative interventions to aid family caregivers who are providing 

home-based care for service-injured veterans. This caregiver burden needs to be 

evaluated to look at ways that the VA can best support them—from the perspective of caregivers who are elderly themselves to our newest generation of 

family caregivers of severely injured OEF/OIF veterans (e.g., parents, siblings, 

grandparents and spouses); and 

• Supports genomic medicine—additional resources should be provided for VA to 

expand its new Genomic Medicine Program. VA’s electronic medical record system allows VA to longitudinally follow its patient population and is uniquely positioned to develop this new science. Genomics offers the possibility of new, 

highly targeted patient treatments in the areas of mental health and chronic 

disease that minimize the effect of adverse reactions to clinical interventions. 

Gulf War Veterans 

Studies indicate about 30 percent of veterans who served in the Gulf War suffer 

from unexplained medical symptoms and illnesses termed Gulf War Illnesses. In 

2004, then VA Secretary Principi committed up to $15 million per year for 5 years 

for Gulf War Illnesses research. The following year VA Secretary Nicholson announced a funding increase and establishment of a research treatment center and 

a pilot program to further study and treat veterans suffering with Gulf War Illnesses. Additionally, the Fiscal Year 2006 Defense Appropriations Act provided $5 

million to DoD’s Gulf War Veterans’ Illnesses Research Program administered 

through the Office of Congressionally Directed Medical Research Program. The seed 

money for this program attracted a remarkable number of proposals (80) indicating 

significant interest to find effective and immediate treatment for Gulf War illnesses; 

however, DoD has excluded additional funding for the program from its proposed 

2008 budget. 

VA’s own Research Advisory Committee for Gulf War Veterans Illnesses notes little effort has been made to utilize VA’s heralded group of research clinicians currently treating Gulf War veterans. No mechanism is currently in place for compiling 

data on treatments and outcomes documented in the medical records of ill veterans 

seen by these VA clinicians. Additional research is needed to explore and compile 

good health outcomes related to efficacious treatments that are used in treating ill 

Gulf War veterans and to share best practices with other VA facilities. 

We believe that while research into causative factors should continue, efforts 

should be made toward more research into treatments and interventions that take 

into account all effective treatments being used by VA clinicians for this population, 

since roughly 200,000 veterans have been suffering from Gulf War illnesses for over 

16 years. 

Minority Veterans 

For many years, the VA has expressed its commitment to eliminating ethnic and 

racial disparities in health care to ensure equal access and quality health care for 


wwoods2 on PRODPC68 with HEARING
55 

all veterans using VA services. In June 2007 the VA Health Services Research and 

Development Service (HSR&D) released a new report, Racial and Ethnic Disparities 

in the VA Healthcare System: A Systematic Review. This research examined a number of clinical interests including: arthritis and pain management; cancer; cardiovascular diseases; diabetes; HIV and Hepatitis C; mental health and substance 

abuse; preventative and ambulatory care; and rehabilitative and palliative care. The 

study concluded that disparities appear to exist in all clinical arenas, and a number 

of hypotheses were suggested to explain why disparities exist. More notably, researchers commented in nearly each case that the underlying causes of disparities 

in care and outcomes were not fully explored or remained unclear. One key finding 

was that in studies examining quality indicators representing immediate health outcomes—such as control of blood sugar, blood pressure, or cholesterol—minority veterans generally fared worse than Caucasians. The researchers noted that this finding was especially troubling since it may indicate that disparities in health care delivery contribute to disparities in health outcomes. It was also noted that fewer 

studies examined Hispanics, American Indians, and Asians and that in general, disparities in the VA appear to impact African American and Hispanic veterans most 

significantly. 

The study relates specific sources of disparities and offers a number of future research recommendations to further elucidate and reduce or eliminate racial disparities in VA health care. It is clear from this study that much more needs to done 

in this area; therefore, we encourage VA to continue this important research. 

Conclusion 

In closing, the Veterans Health Administration is a unique health care system 

with much to offer its large and diverse patient population. And from its earliest 

days, research has been an integral part of VA’s overall mission, while maintaining 

a veteran-centric focus. Today, the VA system offers veterans the ‘‘best care anywhere’’ as reported by independent researchers, the Institute of Medicine, health industry experts and numerous media outlets. Millions of the nation’s sick and disabled veterans need and depend on the VA health care system to help them overcome severely disabling injuries suffered during their military service. We urge VA 

to press forward and to remain on the cutting edge of health care through its esteemed research program, and we encourage this Subcommittee to maintain necessary oversight of VA’s research and to provide sufficient funding so that VA can 

improve services and health outcomes for sick and disabled veterans as it continues 

its quest for excellence. 

Mr. Chairman, this concludes my testimony and I will be happy to address questions from you or other Members of the Subcommittee. 

f 

Prepared Statement of Joel Kupersmith, M.D. 

Chief Research and Development Officer 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Mr. Chairman and members of the Subcommittee, thank you for the invitation to 

appear before you today to discuss the Department of Veterans Affairs (VA) medical 

and prosthetic research program. I appreciate this opportunity to discuss the vital 

role VA research and development has in ensuring the health and well-being of our 

Nation’s veterans. With me are Dr. Timothy O’Leary, Director of Biomedical Laboratory and Clinical Science Research and Development, and Dr. Michael Selzer, Director of Rehabilitation Research and Development. 

Introduction 

Let me first say that the future of medicine is determined by research. Just as 

the advances in medicine that save and improve lives today would not have occurred 

without yesterday’s research, the advances in medicine that we have all grown to 

expect will not occur without today’s and tomorrow’s research. 

Dating back more than 80 years, VA research has been a valuable investment 

with remarkable and lasting returns for veterans and the Nation as a whole. I am 

sure that you are familiar with the many awards won by VA investigators—3 Nobel 

prizes, 6 Lasker awards, and many others. But what is more important is the large 

number of treatments and procedures that have been developed and effectively proven by VA investigators. VA research has taken special advantage of its connection 

to clinical care and is replete with examples of how it has improved care, including: 

• Developing numerous advances in prosthetics, including better-fitting and lighter artificial limbs, prosthetics that can sense, artificial hands that are capable 


wwoods2 on PRODPC68 with HEARING
56 

of very fine motion, a biomechanical foot, and the Seattle foot—a great early 

example of these advances; 

• Pioneering understanding of and treatment for post-traumatic stress disorder 

(PTSD), including exciting new treatment advances proving the effectiveness of 

prolonged exposure therapy and a drug to significantly reduce trauma nightmares and other sleep disturbances in PTSD; 

• Identifying genes associated with Alzheimer’s disease and premature aging; 

• Laying the groundwork for the development of the computerized axial tomography (CAT) scan; 

• Pioneering research efforts leading to new home dialysis techniques; 

• Developing the nicotine patch and other therapies to help smokers quit; 

• Developing the cardiac pacemaker and many other advances for abnormalities 

of heart rhythm, high blood pressure, and coronary artery disease; and 

• Developing a system that decodes brain waves and translates them into computer commands that allow tetraplegics to perform simple tasks like turning on 

lights and opening e-mails by using only their minds. 

VA’s Cooperative Studies Program deserves special mention. It has received national media attention for its groundbreaking work improving treatment for a host 

of critical medical conditions, including: 

• A series of studies that established the cornerstone for treatment of hypertension; 

• One of the first studies to ascertain the long-term effects of coronary artery bypass surgery; 

• An investigative study on the use of cortisone to treat patients with septic 

shock; 

• A landmark study that showed aspirin reduces deaths and heart attacks in patient with unstable chest pain; 

• A vaccine for shingles; 

• New innovative drugs and therapies to treat PTSD; and 

• A study that showed balloon angioplasty plus stenting did little to improve outcomes for patients with stable coronary artery disease who also received optimal 

drug therapy and underwent lifestyle changes. 

But past success is never enough. Research must be future-oriented. VA’s research program builds on its past by identifying and confronting the important 

questions and challenges of today and conducting the hard work to find solutions 

for the future. 

VA Research as a Unique Laboratory 

A particular advantage of VA research is that it is an intramural program where 

clinical care and research occur together under one roof. For this reason, VA has 

the capacity to bring scientific discovery from the patient’s bedside to the laboratory 

bench and then back to the care of patients, making this program one of VA’s most 

effective tools to improve the care of veterans. Embedding research within an integrated health care system with a state-of-the-art electronic health record creates a 

national laboratory for the discovery of new medical knowledge and the translation 

of that knowledge into improved health. Furthermore, the opportunity to conduct research assists VA in recruiting outstanding clinicians and creates a culture of continuous learning and innovation ensuring VA’s continued leadership in health care. 

Additionally, VA research has a unique program, the Quality Enhancement Research Initiative (QUERI), which creates durable partnerships between VA researchers, clinicians, and policy-makers to accelerate the implementation of research 

evidence into routine practice. Allow me to give you one example of this innovative 

program—administration of influenza and pneumococcal vaccine to individuals with 

spinal cord injury. People with spinal cord injury are at higher risk for influenza 

and pneumonia. To increase these patients’ rates of vaccination, VA QUERI investigators partnered with VA clinical leaders in spinal cord injury. Working together, 

they increased the rate of influenza vaccination from 28 to 61 percent, and the rate 

of pneumonia vaccination from 40 to 79 percent. These improvements continued 

even after the initiative ended, with the vaccination rates reaching 72 and 86 percent, respectively, when last measured. 

This advance for veterans with spinal cord injury can be attributed to researchers 

working within VA’s health delivery system to improve the process of care. I think 

this exemplifies the value of having research and clinical care ‘‘under one roof’’, 

working together to improve the delivery of care. 


wwoods2 on PRODPC68 with HEARING
57 

Priorities of VA Research 

Each year we re-evaluate our priorities based on the changing needs of the veterans we serve, and strive to fund the highest quality science that meets those priorities. The following are some of the current priority areas for VA research: 

• Research related to Operation Enduring Freedom and Operation Iraqi Freedom 

(OEF/OIF) veterans and deployment health; 

• Mental health; 

• Personalized medicine; 

• Chronic diseases; 

• Access to care; 

• Long-term care; and 

• Women’s health. 

Details about these priority areas are given below. 

Research Related to Operation Enduring Freedom and Operation Iraqi 

Freedom (OEF/OIF) Veterans and Deployment Health 

VA has implemented a comprehensive research agenda to develop new treatments 

and tools for clinicians to ease physical and psychological pain, improve access to 

VA health care services, and address the full range of health issues of OEF/OIF veterans. This research also has direct relevance for veterans of other conflicts, as well 

as for civilians suffering from disability due to injury or disease. 

Specific areas of focus in OEF/OIF and deployment health related research include: 

• Traumatic Brain Injury (TBI) and Other Neurotrauma 

Although Kevlar helmets and improved body armor save lives, they do not protect 

against blasts and impacts to the head, face, and cervical region of the spinal cord. 

Those that survive blast force and impacts may suffer injuries to internal organs, 

limb loss, sensory loss, paralysis, cognitive loss, chronic pain, and psychological disorders. 

To advance the treatment and rehabilitation of soldiers returning with these types 

of injuries, VA issued a request for research proposals that focus on TBI; cervical 

spinal cord injury (SCI); co-morbid conditions such as PTSD and trauma to extremities; screening and diagnostic tools related to mild TBI, especially field-based; and 

continuity of care between the Department of Defense (DoD) and VA. Applicants 

were asked to pay special attention to cooperative projects with DoD. 

Many exciting projects have emerged from this solicitation and other funding 

mechanisms to help veterans suffering from TBI, including: (1) studying neural repair after brain injury to build a better understanding of cognitive rehabilitation, 

as well as find potential targets for practical treatments that enhance quality of life; 

(2) developing a project exploring community re-integration for servicemembers with 

TBI (to promote seamless transition between servicemembers currently being treated, or who will one day be treated, in both DoD and VA medical facilities); and (3) 

several studies assessing the relationship between TBI and PTSD and their impact 

on health outcomes. 

In addition, several VA scientists with expertise in neuroimaging and neuropsychology are turning their efforts to further understanding the brain changes that 

occur in TBI. This is important because following TBI there may be subtle or distinct brain damage that results in memory, attention, thinking, and personality 

changes that are difficult to diagnose and treat with current knowledge. A new 

study will start this year combining state-of-the-art imaging techniques (e.g., threedimensional brain imaging and diffuser tensor imaging to examine white matter 

changes) with comprehensive neuropsychological assessments to fully characterize 

patients with TBI compared to other types of brain damage such as stroke. Knowledge from this study will help inform rehabilitation and diagnostic strategies. 

VA researchers are also studying many ways to help veterans with SCI. Investigators are developing practical functional electrical stimulation systems that may 

allow individuals with incomplete SCI to walk. VA researchers are also preparing 

to conduct clinical studies of a neuroprosthetic system for restoration of hand–arm 

function in veterans with a cervical level SCI. It is hypothesized that users will 

demonstrate significant improvements in their pinch strength, range of motion, and 

their ability to perform grasp-release tasks with their hands and also show better 

control of their forearms and elbows. VA investigators are also testing microstimulators to recreate breathing and coughing patterns that will avoid respiratory complications which are currently the leading cause of death in SCI patients. Further, 

VA researchers are continuing to improve the mobility and function of veterans with 


wwoods2 on PRODPC68 with HEARING
58 

SCI and other disabilities through innovative engineering for wheelchairs and other 

assistive technologies. 

In one exciting study, VA researchers and others recently demonstrated that a 

neuromotor prosthesis (NMP) could enable a tetraplegic to operate an artificial 

hand, robotic arm, computer, or television by using only his thoughts (Nature. 2006; 

442(7099):164–171). A NMP is a brain-computer interface that helps replace or restore lost movement in paralyzed patients. This technology uses an electrode that 

picks up brain signals and sends them to a computer for decoding. The brain signals 

are translated into commands to power electronic or robotic devices, including prosthetics. 

One of the most common conditions in returning OEF/OIF veterans due to blast 

exposure is tinnitus (ringing noise in the ear). VA researchers are developing a diagnostic test to identify this condition, which is currently done by self-report. In collaboration with DoD, VA investigators are planning a study to determine which auditory processing disorders are more often associated with exposure to high-explosive blasts, whether there is spontaneous recovery of auditory function after blast 

exposure, how much recovery may be expected, and how rapidly it occurs. 

In addition, VA investigators are developing behavioral strategies to cope with 

conditions of low vision and blindness. VA researchers also continue to make 

progress on the development of an artificial retina for those who have lost vision 

due to retinal damage. As reported in one recent publication, the threshold electrical 

current needed to stimulate the retina of a rabbit in which the device was implanted 

was very low (Journal of Neural Engineering. 2005; 2(1):S48–S56). This was encouraging because using lower currents would reduce the chance of damage to surrounding eye tissue. Analogous approaches may prove useful in combat-related vision loss. 

• Combat-related Mental Health 

Among active duty Army and Marine Corps personnel who participated in combat 

during OEF/OIF, 11.2—17 percent reportedly met screening criteria for major depression, generalized anxiety disorder, or PTSD. These areas of readjustment mental health disorders are actively being pursued in ongoing VA research. 

In a landmark 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 afterward, to identify possible changes that occurred in emotions or thinking 

following their combat duty in Iraq and to identify predisposing factors to PTSD as 

well as other health conditions. To date, researchers have already reported that 

troops who had served in Iraq showed mild deficits in some tasks of learning, memory, and attention, but scored better on a test of reaction time, compared with nondeployed troops. The researchers have proposed longitudinal follow-up studies to determine if these neuropsychological effects might fade over time, or be a precursor 

to PTSD (Journal of the American Medical Association. 2006; 296(5):519–529). An 

additional goal for this research is to examine the neuropsychological associations 

of TBI with the development of PTSD at long-term follow-up. 

Veterans with PTSD commonly experience nightmares and sleep disturbances, 

which can seriously impair their mood, daytime functioning, relationships, and overall quality of life. In an exciting new treatment development, VA investigators have 

found that prazosin, an inexpensive generic drug already used by millions of Americans for high blood pressure and prostate problems, improved sleep and reduced 

trauma nightmares in a small number of veterans with PTSD (Biological Psychiatry. 2007; 61(8):928–934). Plans are under way for a large, multi-site trial to confirm the drug’s effectiveness. 

One of the more interesting recent findings in PTSD research being pursued in 

the field now is the idea that traumatic memories may be ‘‘extinguished’’ or weakened with a medication administered as the memory is ‘‘replayed’’ or reactivated 

under controlled circumstances. A small clinical trial is being conducted to determine whether the drug, propranolol, is more effective than a placebo in reducing 

PTSD symptoms such as hyper-arousal, re-experiencing, or avoidance when a distressing memory is reactivated. Research participants will be veterans of the Iraq 

or Afghanistan conflicts. 

In addition, VA investigators are currently conducting the first ever clinical trial 

of a medication to treat military service-related chronic PTSD. It will also be the 

largest placebo controlled, double-blind study of its kind ever conducted, meaning 

that it is the most rigorous type of clinical trial. It will involve 400 veterans diagnosed with military-related chronic PTSD from 20 VA medical centers (VAMCs) nationwide. The main objective of the study is to determine if risperidone is effective 


wwoods2 on PRODPC68 with HEARING
59 

in veterans with chronic PTSD who continue to have symptoms despite receiving 

standard medications used for this disorder. 

Risperidone is being studied since it has been shown to be safe and has received 

the most study in the treatment of PTSD patients. 

• Pain 

Veterans from all eras may experience chronic pain related to traumatic injuries. 

Accordingly, VA has issued a solicitation for research proposals that seek to develop 

novel approaches for the treatment and management of chronic pain associated with 

TBI, SCI, amputation, and burn injury that may result from OEF/OIF deployment 

as well as multiple sclerosis and other disorders. 

Excruciating pain is experienced by more than 50 percent of patients after SCI. 

VA investigators have identified a particular form of sodium channel (of which there 

are more than 10) responsible for conveying pain signals to the brain (Nature. 2006; 

444(7121):831–832). VA researchers are now exploiting this finding to develop a new 

pain treatment. 

In addition, VA and DoD are jointly funding a study to examine the short- and 

long-term benefits of implementing early advanced regional anesthesia techniques 

for pain control following major traumatic injuries to extremities encountered during OEF/OIF combat. It is hoped that these techniques will result in a significant 

reduction in pain disability as well as in the incidence and severity of mental health 

disorders due to early pain intervention on the battlefield. 

It is well-known that limb trauma causing fractures and/or nerve injuries can lead 

to the development of a disorder called complex regional pain syndrome (CRPS). To 

address this issue, VA researchers have developed a rat fracture model resembling 

CRPS. Using molecular approaches, the investigators will attempt to characterize 

chronic changes in key mediators such as cytokine signaling after limb trauma, 

which will demonstrate the feasibility of promising new treatments for post-traumatic pain and inflammation. This work could potentially be an important step toward the ultimate goal of improving clinical efficacy and safety in the pharmacologic 

management of CRPS. 

• Prosthetics and Amputation Health Care 

While nearly two-thirds of adult amputations may arise due to peripheral vascular disease of the lower extremity, they are complemented by those necessitated 

by trauma, in the present case, the trauma related to high explosive blasts or 

through other combat scenarios. High-impact explosive trauma from improvised explosive devices has become the signature injury of the OEF/OIF theaters. 

Tendon losses are common in military trauma and in degenerative diseases such 

as rheumatoid arthritis and osteoarthritis. In mutilating injuries, a tendon grafted 

from another part of the individual’s body may improve function; however, only a 

limited supply of these tendon grafts exists. VA investigators are working to create 

biocompatible tissue-engineered tendon grafts, which will have wide applicability in 

improved reconstruction of extremities for veterans. 

In addition, joint cartilage may be lost or degenerated as a result of trauma, disease, or aging, which leads to reduction in mobility and quality of life. VA investigators are using tissue engineering methods to develop an implant that can help regenerate cartilage. 

The care of the wounds following amputations has been the subject of extensive 

research. This type of wound care is particularly challenging, owing more to the conditions surrounding the original injury than those of the surgery. VA researchers 

are investigating three management strategies in current standard of care for residual limbs after surgery: (1) soft dressings, (2) rigid plaster dressing, and 

(3) commercial prefabricated rigid prostheses. Studies of this nature are critical to 

a better understanding of wound care in a variety of settings extending from the 

‘‘dirty’’ wound characteristic of a roadside bombing all the way to the healing capacities in an elderly diabetic veteran. These kinds of studies can potentially improve 

outcomes of amputations and burns. Most critically, improved wound healing methodologies actually have the potential to minimize the need for amputation itself. 

VA researchers are also developing improved materials and designs of prostheses. 

In addition, VA investigators are gathering information about how prosthetic devices are used, amputee satisfaction, comparisons of selected prosthetic devices, associated costs, and various prosthetic procurement alternatives, so VA can better 

match technology to an individual veteran’s needs. 

Another project that is under way involves building a new flexible externally powered two-degree-of-freedom prosthetic wrist for use in upper-extremity prostheses. 

This will provide prosthetic users with electric-powered prosthetic components that 


wwoods2 on PRODPC68 with HEARING
60 

interact with objects in a more lifelike fashion and devices that will be more robust 

and less prone to mechanical failure. 

Currently available prostheses for trans-tibial (below the knee) amputees do not 

help promote normal walking; in fact, their ‘‘passive’’ design can result in balance 

difficulties and slow walking speed. VA has funded research that addresses this 

problem by developing a powered ankle–foot prosthesis that promises to help restore 

amputees’ ability to walk normally. A preliminary study involving three trans-tibial 

amputees confirmed the benefits of the new prototype: the patients expended less 

energy during walking, had fewer balance problems, and walked 15 percent faster. 

This device has recently received significant media attention. 

• Polytrauma 

As a result of new modes of injury (improvised explosive devices), improved body 

armor, and surgical stabilization at the frontline of combat, more soldiers are returning with complex, multiple injuries (‘‘polytrauma’’), including amputations, 

brain and spinal cord injuries, eye injuries, musculoskeletal injuries, vision and 

hearing loss, burns, nerve damage, infections, and emotional adjustment problems. 

In response, VA has established a Polytrauma and Blast-Related Injury (PT/BRI) 

QUERI coordinating center to promote the successful rehabilitation, psychological 

adjustment, and community reintegration of these veterans. Two priorities have 

been identified: (1) TBI with polytrauma, and (2) traumatic amputation with 

polytrauma. The primary target is OEF/OIF VA patients, many of whom remain on 

active duty during their initial course of treatment in VA. However, the center’s activities will benefit all VA patients with complex injuries, regardless of service era 

and mechanism of injury. 

The PT/BRI QUERI is working closely with VA Polytrauma Rehabilitation Centers (PRCs) to identify needs and gaps in care, as well as best practices. For example, one needs assessment study found that PRC patients are demographically and 

clinically different from inpatient rehabilitation patients treated before OEF/OIF. 

The systems of care, facilities, and individual health care teams are rapidly changing to meet the needs of these unique patients. 

VA also recently issued a special solicitation for research projects on the long-term 

care and management, including family and community reintegration, of veterans 

with polytrauma, blast-related injuries, or TBI. 

• Gulf War Veterans’ Illnesses 

While there were few visible casualties associated with the 1990–1991 Gulf War, 

many individuals returned from this conflict with unexplained medical symptoms 

and illnesses. Nonspecific symptoms such as fatigue, weakness, gastrointestinal difficulties, cognitive dysfunction, sleep disturbances, headaches, skin rashes, respiratory problems, and mood changes that often occur together in a constellation 

have been termed Gulf War veterans’ illnesses (GWVI). Despite a large number of 

studies and considerable funding over the past decade, the causes and successful 

treatment of GWVI remain illusive. VA continues to expand its efforts to understand and treat GWVI. 

There is also persistent concern that Gulf War veterans may be at increased risk 

for amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease), multiple 

sclerosis (MS), and brain cancer, as a result of their service. In addition to the studies that examine the causes and treatment of these diseases in the general veteran 

population, VA is funding studies to examine them specifically in Gulf War veterans. Accordingly, VA is supporting a broad research portfolio composed of studies 

dedicated to understanding chronic multi-symptom illnesses, long-term health effects of potentially hazardous substances to which Gulf War veterans may have 

been exposed to during deployment, and conditions or symptoms that may be occurring with higher prevalence in Gulf War veterans. 

Beyond OEF/OIF and deployment health related research, VA’s research priorities 

include several areas affecting the larger veteran population, including: 

Mental Health Research 

In addition to combat-related mental health, VA continues to support a strong behavioral and psychiatric disorders research portfolio focused on further understanding and treating mental health problems in veterans. Investigations are directed toward substance abuse, PTSD, adjustment and anxiety disorders, psychotic 

disorders, dementia and memory disorders, and related brain damage. Many laboratory studies are being conducted to better understand the changes that take place 

when someone is suffering from adjustment problems or mental illness. Clinical 

trials are under way to test novel drug and therapy treatments specifically targeted 

to help veterans. Additionally, VA has a strong program for developing and implementing better mental health care, including enhancing collaborative care models, 


wwoods2 on PRODPC68 with HEARING
61 

improving access to mental health care through innovations such as telemedicine 

and the Internet, and reducing barriers to veterans seeking mental health care. Several ongoing projects are investigating how veterans with mental illness might benefit from rehabilitation approaches, including vocational rehabilitation, skills training, and cognitive therapy to improve everyday functioning and work performance. 

Future research will enable VA to determine how to care for veterans with mental 

illness so that they can return to their highest level of functioning. 

Personalized Medicine 

Personalized medicine means tailoring care to the individual, in this case the veteran. In 2006, VA launched the Genomic Medicine Program as part of its Personalized Medicine Initiative. Genomic medicine is the direction for health care in the 

twenty-first century. It could allow VA to provide care that is tailored specifically 

to the genetic makeup of individual veterans, increasing the effectiveness and safety 

of health care and disease prevention efforts. Currently, VA is funding over 140 research projects related to genomics. These include studying the complete set of DNA 

of many people to determine what genetic changes are associated with a certain disease (genome-wide scans), the role of specific genes, and genetic determinants of 

variable responses to drugs (pharmacogenomics). These studies are investigating the 

role of genetics in many diseases of importance to veterans—including psychiatric 

disorders (e.g., schizophrenia, depression, PTSD, and anxiety); cancers of the prostate, breast, colon, lung, and bladder; heart disease; diabetes; Alzheimer’s disease; 

stroke; Parkinson’s disease; autoimmune disorders, including rheumatoid arthritis 

and lupus; GWVI; and chronic viral infections such as HIV. 

VA investigators recently conducted a genome-wide search for schizophrenia susceptibility genes. The study included 166 families with more than two affected individuals, from seven VAMCs. There are 216 affected sibling pairs in these families, 

comprising the largest North American sample of schizophrenic sibling pairs to date. 

Preliminary data from the researchers’ genome scan suggest the involvement of a 

small region on chromosome 18. The team will continue to narrow the search by 

fine-mapping this region and seeking specific genes. 

VA has established a Genomic Medicine Program Advisory Committee (GMPAC) 

comprised of the nation’s leading clinicians, scientists, administrators, as well as 

veteran representatives. The Committee has recommended the establishment of several working groups. It has also discussed issues such as who should have access 

to data generated by this program, assessment of veterans’ attitudes toward 

genomic medicine, and establishing veterans’ trust. 

An Ethics Advisory Working Group, which will report through the GMPAC, has 

also been established. Members of this working group include bioethicists, a member 

of the clergy, and veterans. The first meeting of this group was in May 2007. Topics 

of discussion included the ethics of the informed consent document, special populations (e.g., those with mental illness), and the role of group vs. one-on-one discussions for educating veterans about the program. 

In addition, last week VA held the first meeting of its PTSD Genetics Working 

Group to explore and define a research program to identify the genes that are important in how an individual responds to the experience of deployment, especially 

their response following combat exposure. By carefully characterizing those affected 

by combat-related PTSD and conducting genetic analyses, VA will be in a position 

to identify genetic variants that contribute to PTSD and other post-deployment adjustment disorders such as major depression. Once this program is established, this 

resource will be available for continued research including studying the genetic relationship to treatment response. 

Chronic Diseases 

Promoting good health and managing chronic conditions remain high priorities for 

VA health care and VA research, especially in the aging veteran population. The 

following are examples of efforts by VA investigators to discover how to prevent and 

treat chronic diseases. 

• Diabetes 

Nearly a quarter of the veterans receiving care from VA have diabetes, and a far 

greater number (73 percent) are at risk due to overweight or obesity. VA researchers 

are studying innovative strategies and technologies—including group visits, telemedicine, peer counseling, and Internet-based education and case management—to 

improve access to effective diabetes care and outcomes. In addition, VA investigators 

have initiated studies to identify and define the impact of traditional rehabilitation 

treatment for veterans who have diabetes, and to develop innovative treatments to 

prevent and improve diabetes outcomes in special populations such as the elderly, 

amputees, minorities, and spinal cord injured veterans. VA is also supporting major 


wwoods2 on PRODPC68 with HEARING
62 

clinical trials on treating kidney disease and coronary artery disease in diabetic patients. 

It has been long known that type 2 diabetes runs in families and that certain populations are at a higher risk than others (e.g., Hispanic veterans and American Indian veterans). However, it was not until the recent advances in genetic technologies that researchers began to investigate associations between specific genes 

and diabetes. 

VA investigators have been honing in on genes that boost the risk for type 2 diabetes and obesity. Working with Mexican-American families enrolled in the Veterans Administration Genetic Epidemiology Study, VA investigators have compared 

small differences in the DNA of people with and without the disease. Earlier work 

by members of the group had suggested that a specific region of chromosome 6 was 

involved. This region contained several hundred genes, and initially it was not clear 

which gene played a role in causing disease. But using recent advances in genomesequencing, the researchers have combed through the region and narrowed their 

search to seven genes. The precise functions of these genes are still unknown. Two 

are involved in metabolic pathways not previously connected with diabetes or obesity. The remaining five appear to be ‘‘master regulators’’ that can alter the expression of hundreds of other genes. Ongoing research is aimed at determining how 

these genes raise the risk of diabetes and obesity. 

• Obesity 

The VA patient population, like that of the U.S. in general, is experiencing an epidemic of overweight and obesity. In terms of treatment options, recent findings from 

VA investigators indicate that surgical treatment is more effective than diet and 

medications for weight loss in severely obese patients. Weight loss was maintained 

for up to 10 years or longer, and it was accompanied by significant improvements 

in diabetes, hypertension, and high cholesterol (Annals of Internal Medicine. 2005; 

142(7):547–559; Annals of Internal Medicine. 2005; 142(7):532–546). 

Ongoing VA studies are seeking to identify and define the impact of traditional 

rehabilitation treatment for overweight and obese veterans, and also to develop 

unique treatment measures to prevent and improve obesity outcomes. In addition, 

VA researchers are investigating the influence of obesity on the quality of care that 

veteran patients receive. VA investigators are also focusing on unique populations 

at risk for obesity, such as patients with spinal cord injury. 

• Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/ 

AIDS) 

VA is the largest single provider of HIV care in the U.S., with nearly 20,000 patients with the disorder treated annually. Accordingly, VA funds a full range of 

studies from bench research aimed at elucidating the underlying mechanisms of 

HIV to implementation projects that improve VA’s effectiveness in caring for this 

population. 

VA investigators recently showed that people with a below-average number of copies of a particular immune-response gene have a greater likelihood of acquiring HIV 

and, once infected, of progressing to full-blown AIDS. Researchers examined blood 

samples from 4,308 HIV-positive and HIV-negative volunteers of various geographical ancestries. Depending on the study sub-population, each copy of the gene 

CCL3L1 decreased the risk of HIV infection by 4.5 to 10.5 percent. These findings, 

cited as one of the top articles published in the eminent journal Science in 2005, 

have important implications for the treatment and prevention of HIV infection and 

AIDS, and possibly other infectious diseases as well (Science. 2005; 307:1434–1440). 

The same group has gone on to show that a person’s genetic makeup—in this 

case, the genes CCL3L1 and CCR5—could be a more accurate predictor of disease 

progression than currently used laboratory markers, such as CD4+ T cell counts and 

viral loads. The researchers also demonstrated that the combination of laboratory 

and genetic markers captures a broader spectrum of AIDS risk than either set of 

markers alone (Journal of Immunology. 2007; 178:5668–5681). 

• Heart Disease 

Heart failure is the most common diagnosis causing hospitalization of veterans, 

with resulting high costs and resource utilization over time. VA researchers recently 

found that the use of an implanted defibrillator reduced the risk of dying and improved quality of life for veterans with heart failure (Journal of the American College of Cardiology. 2005; 45(9):1474–1481). VA researchers are also studying noninvasive care for heart failure. In addition, nurse researchers are preparing to link 

biochemical markers of heart failure with patterns of depression to aid in earlier 

screening and treatment for depression in patients with heart failure. Nurse reVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00066 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
63 

searchers are also exploring the role patients can play in their own heart failure 

care. 

Coronary artery disease, a narrowing of the arteries that supply blood to the 

heart muscle, is the leading cause of death in both men and women. More than half 

a million Americans die each year from coronary artery disease. 

A U.S.-Canadian trial sponsored in part by VA’s Cooperative Studies Program 

found that balloon angioplasty plus stenting did little to improve outcomes for patients with stable coronary artery disease who also received optimal drug therapy 

and underwent lifestyle changes. The researchers concluded that if a patient with 

heart disease is doing well on medical therapy alone, there is no added preventive 

benefit to angioplasty and stenting (New England Journal of Medicine. 2007; 

356:1503–1516). 

Access to Care 

VA has a prominent and unique role in meeting the health care needs of veterans 

and ensuring equitable access to quality care for the most recent veterans, veterans 

from previous service eras, vulnerable populations who rely on VA for health care, 

and future veterans. The VA health care system continues to strengthen efforts to 

improve health care to veterans by identifying barriers to care and assessing and 

implementing system improvements to improve access to quality care. VA research 

supports and guides these system improvements through a diverse range of studies 

that analyze factors and interventions impacting access to the VA health care system. VA research identifies system-wide gaps in care to veterans; assesses specific 

access issues and barriers to care for special populations; assesses the impact of new 

programs, practice structures, and organizations of care on access and quality of 

care; and develops and evaluates the impact of quality improvement efforts, organizational and management interventions, implementation initiatives, and new technologies on improved access and health care to veterans. 

Over the past decade, VA has added to the number of Community-Based Outpatient Clinics (CBOCs) to increase access to primary care for veterans. CBOCs 

have been an integral part of VA’s transition from an inpatient-oriented system to 

an outpatient-oriented system. A VA study compared inpatient and outpatient utilization and expenditures of veterans seeking primary care in 108 CBOCs and 72 affiliated VAMCs in fiscal years 2000 and 2001. Findings show that CBOCs provided 

veterans with improved access to primary care and other services, but costs were 

contained because they had fewer health care visits and hospital stays than veterans receiving care at VAMCs. These results held even after adjusting for demographics, patient risk, and distance from care. CBOC patients had significantly 

lower odds of having specialty, mental health, or ancillary (e.g., radiology, laboratory, other outpatient) visits than VAMC patients. CBOC patients also were less 

likely to be hospitalized (BioMed Central Health Services Research; 7(1):56). 

Evidence-based practices designed for large urban clinics are not necessarily 

transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because often onsite mental health specialists cannot be hired. The Telemedicine-Enhanced 

Antidepressant Management (TEAM) study evaluated a collaborative care model 

adapted for small rural VA CBOCs using telemedicine technologies (interactive 

video equipment for mental health and no on-site psychiatrists/psychologists). Participants in the intervention had better medication adherence, were more likely to 

respond to treatment, and were more likely to experience a remission than those 

with usual care. Patients also had better quality of life and higher satisfaction. 

These findings suggest that collaborative care models can be successfully adapted 

using telemedicine to address rural disparities (General Hospital Psychiatry. 2006; 

28(1):18–26; Psychiatric Services. 2006; 57(12):1731–7). 

In addition, VA is beginning a new access to care research initiative for OEF/OIF 

veterans that will build on the body of VA research examining access to care issues 

and innovations. This research is expected to enhance OEF/OIF veterans’ access to 

practices that improve well-being and function after physical injury sustained in 

war, that mitigate suffering due to chronic medical conditions, and that are effective 

for the treatment needed by veterans returning from the wars in Iraq and Afghanistan. It is hoped that VA’s OEF/OIF access research initiative will help facilitate 

improved access to care for eligible veterans and more efficient and effective systems 

of care that meet the health care needs of the OEF/OIF veteran population. 

Long-term Care 

Meeting the long-term care needs of veterans is growing in importance as the 

number of veterans most in need of these services—those 85 years old and older— 

is expected to reach 1.3 million by 2012. In addition, a younger population of vetVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00067 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
64 

erans with different long-term and care coordination needs is emerging as a result 

of the OEF/OIF conflicts. 

Many veterans prefer to receive long-term care in non-institutional settings, so 

they can stay connected with their community and loved ones. However, the success 

of such long-term care is critically dependent on the ability of veterans’ family and 

friends to assist in their care. Caregiver burden is common and frequently limits 

the ability of family and friends to provide assistance. Caregiving can also have significant negative consequences on the health and well-being of caregivers, yet little 

is known about how to ameliorate the impact of the burden of care. VA has initiated 

several efforts to understand and support the needs of caregivers. These include special efforts to survey the needs of caregivers of blast injury and TBI patients, as 

well as a research initiative focused on developing new approaches to communitybased long-term care. 

In addition, VA is funding several projects to assess the effectiveness of telemedicine technologies for rehabilitation of veterans who are older, disabled, and/or in difficult to reach, rural areas as compared to home visits by health care personnel and 

usual care. Tele-rehabilitation may be particularly useful for older and disabled veterans with long-term care needs because it empowers them to take responsibility 

for their own health by providing ongoing communication with the VA health care 

system and may allow them to remain independent in their homes as long as possible. 

Women’s Health 

In response to the increasing number of women veterans, documented expansion 

of the number of women in the military, and special health care needs of female 

veterans, VA has focused additional attention on women’s health research. VA research efforts are aimed at better understanding the general health care needs and 

service utilization of women veterans; examining the unique experiences of women 

veterans regarding risks, treatment, and health care outcomes related to military 

traumas; and assessing VA’s organization of care for women veterans and the implications for improved quality of care. 

Examples of VA research studies relevant to women veterans’ health include further understanding the cellular mechanisms underlying breast and cervical cancers, 

the role of hormones in stroke and aging, further characterizing basic 

neurobiological changes in women who have undergone severe trauma, and specific 

prosthetic designs for women. 

In the largest randomized clinical trial to date involving women veterans with 

PTSD, VA investigators and colleagues found that prolonged-exposure therapy—a 

type of cognitive behavioral therapy—was effective in reducing PTSD symptoms and 

that such reductions remained stable over time. Women who received prolonged-exposure therapy—in which therapists helped them recall their trauma memories 

under safe, controlled conditions—had greater reductions of PTSD symptoms than 

women who received only emotional support and counseling focused on current problems (Journal of the American Medical Association. 2007; 297(8):820–830). Together 

with a strong mental health research program, VA research is well positioned to 

continue to enhance health care for women veterans. 

Conclusion 

Because more than 70 percent of VA researchers are also clinicians caring for veterans, VA is uniquely positioned to move scientific discoveries from investigators’ 

laboratories into patient care. In turn, VA clinician investigators can identify new 

research questions for the laboratory at the patient’s bedside, making research one 

of VA’s most effective tools to continue improving the care of veterans. The fundamental goal is to address the concerns of the entire veteran population from the 

youngest soldier who returns with injuries from recent conflicts to the aging veteran, and to use research findings proactively to benefit the future veteran. VA 

takes great pride in the research that keeps it at the forefront of modern medicine 

and health care and expects to see further remarkable discoveries in the coming 

decades. 

Mr. Chairman, that concludes my statement. I am pleased to respond to any questions you or the Subcommittee members may have. 

Thank you. 

f 


wwoods2 on PRODPC68 with HEARING
65 

Statement of National Association of Veterans’ Research and Education 

The National Association of Veterans’ Research and Education Foundations 

(NAVREF) appreciates the opportunity to submit a statement for the record of the 

hearing being conducted on October 4, 2007, by the Health Subcommittee of the 

House Committee on Veterans Affairs regarding the Department of Veterans Affairs 

(VA) Medical and Prosthetic Research program. 

NAVREF is the voluntary membership association of the VA-affiliated nonprofit 

research and education corporations (NPCs) established and operated in accordance 

with 38 U.S.C. §§73617368. NAVREF’s mission is to promote high quality management and communication among the NPCs, and to pursue issues at the government 

level that are of interest to its members. NAVREF accomplishes this mission 

through education, interactions with agency and congressional officials, and advocacy. Additional information about NAVREF is available on its Web site at 

www.navref.org. 

Background About the NPCs 

In 1988, Congress allowed the secretary of the Department of Veterans Affairs to 

authorize ‘‘the establishment at any Department medical center of a nonprofit corporation to provide a flexible funding mechanism for the conduct of approved research and education at the medical center.’’ [38 U.S.C. §7361(a)] At this time, 85 

facilities are taking advantage of this authority, providing each VAMC with a highly 

valued means for administering non-VA federal and private sector funds in support 

of VA research and education. 

We encourage the Subcommittee to review the VA’s most recent report on the 

NPCs which VA submitted to Congress in accordance with requirements stated at 

38 U.S.C. §7366(b) through (d). This compilation of information provided by NPCs 

presents a comprehensive overview of NPC revenues and expenditures, the activities they support and the oversight provided by VA through the VA NPC Program 

Office and the VA NPC Oversight Board as well as annual audits by independent 

auditors. This report demonstrates that NPCs have become an integral component 

of VA facility research programs, administering $227 in non-VA federal and private 

sector revenues and approximately 5000 projects at any one time during the last 

year. 

NPCs are fully dedicated to serving the needs of VA research and VA investigators. In the course of administering research, they support a variety of project-related costs such as salaries for research personnel, supplies, equipment and travel 

for scientific conferences and training. Additionally, they support a number of activities that foster a vibrant research environment at VA medical centers across the nation. Such activities include supporting institutional review boards (IRB) and other 

compliance measures, core research equipment and services, seed and bridge funding and VA staff recruitment. NPCs also donate to VA the services of approximately 

2500 NPC research employees who work under VA without compensation (WOC) appointments with the background, security and training requirements such appointments entail—side-by-side with VA-salaried employees. 

Current Reviews of NPCs and Oversight 

Internal control failures experienced by three NPCs in 2006 prompted the VHA 

Office of Finance and the Office of the Inspector General (IG) to undertake separate 

reviews of the NPCs that were performed during 2007. Although we believe that 

NPC boards and employees are for the most part conscientious stewards of NPC 

funds, NAVREF applauds VA for acting forthrightly to confront NPC management 

deficiencies that do come to light, and we consider the results of these reviews to 

be learning opportunities for NPCs. We have invited both the VHA and IG auditors 

to present their objectives, methodologies, findings and recommendations during the 

NAVREF 2007 Annual Conference in November so that all of the NPCs may learn 

from VA’s substantial investment in conducting the reviews. The IG report, which 

originally was scheduled for completion in August, is not yet complete, but we remain hopeful that it will be published in time for discussion during the conference. 

Additionally, eight hours of the NAVREF conference program will be devoted to internal controls training for both large and small organizations, and VA is planning 

separate training specifically for members of NPC boards. NAVREF anticipates 

using the IG’s recommendations to focus its own future educational programs on 

areas identified to be in need of improvement. 


wwoods2 on PRODPC68 with HEARING
66 

To improve VA oversight of NPCs, we encourage the Subcommittee to support the 

Office of Research and Development’s plan to recruit as director of the VA Nonprofit 

Program Office a fully dedicated GS–15 with expertise in nonprofit management, accounting and governance. This office is tasked with providing NPC oversight and 

when staffed with the appropriate level of expertise will be a welcome partner in 

ensuring high standards of NPC management. 

Proposal to Update and Clarify the NPC Authorizing Statute 

Nearly two decades after enactment of Public Law 100–322, the success of the 

NPCs in supporting VA research and education demonstrates that the NPC authorizing statute has been effective in accomplishing Congress’s purpose of providing VA 

with flexible funding mechanisms for the conduct of VA-approved research and education. Its authors successfully crafted a unique private-public partnership that has 

served VA facility research programs and investigators well. However, during the 

intervening years, VA health care delivery systems, the VA research program and 

the NPCs have evolved. Prompted in part by the upcoming twentieth anniversary 

of the authority to establish NPCs, during the last twelve months the NAVREF 

board conducted a comprehensive review of the NPC authorizing statute in light of 

accumulated years of experience working within its terms. 

After much deliberation, and discussions with the Office of Research and Development and the VA Office of General Counsel as well as Paralyzed Veterans of America and staff of the House and Senate Committees on Veterans Affairs, NAVREF 

concluded that it would be of benefit to VA and the NPCs to update and clarify the 

NPC authorizing statute. This will also benefit veterans by helping NPCs meet their 

full potential in supporting VA research and education that ultimately results in improved treatments and high quality care for veterans. Guided by these discussions, 

early this year NAVREF began developing a statutory proposal that is nearing completion and that we expect to submit to Congress in December for consideration and 

enactment during the second session of the 110th Congress. 

NAVREF’s primary objective in proposing statutory revisions is to allow ‘‘multisite’’ NPCs. That is, voluntary sharing of one NPC among two or more VAMCs while 

still preserving their fundamental nature as medical facility-based organizations. 

We have two purposes for seeing this objective. First, it would allow VAMCs with 

small research programs to join with larger ones or for several small programs to 

join together to pool their resources for purposes of efficiency and ensuring sound 

management. Second, it would allow reasonable, but not overly burdensome, board 

composition by requiring the medical center director of each facility to serve on the 

board to ensure local accountability. Otherwise the board of a multi-site NPC would 

be required to have as VA members just one Chief of Staff, Associate Chief of Staff 

for Research and Associate Chief of Staff for Education. Beyond this proposed statutory minimum, our proposal would leave it up to each multi-site NPC board to determine the combination of VA and non-VA members best suited to its own needs. 

In our view, requiring all of these personnel from each facility to serve on the board 

is not a good use of their valuable time and results in an unnecessarily large and 

logistically cumbersome board. 

This change in the NPC statute would benefit VA by reducing the number of 

NPCs that VA is required to oversee and would eliminate the need for duplicative 

local effort at the same time as it would increase the resources each NPC would 

have available for management. NAVREF anticipates that as many as twenty lowrevenue VA research programs may welcome the opportunity to partner with other 

nearby facilities to share NPCs. 

NAVREF’s other proposed revisions in the NPC authorizing statute are designed 

to clarify—not change—the legal status of the NPCs as independent organizations, 

exempt from taxation under Section 501(c)(3) of the Internal Revenue Service (IRS) 

code and subject to VA oversight and regulation. Additionally, proposed revisions 

clarify the NPCs’ purposes as well as their funds acceptance and expenditure authorities. Our objective in making these changes is to resolve longstanding uncertainty and sometimes outright confusion and disagreement among VA officials, internal VA and external overseers, funding organizations and NPC personnel. 

NAVREF is also suggesting a general re-organization of the statute to pull together 

in separate sections the various provisions addressing status, purposes and powers. 

As NAVREF considered statutory revisions, it also identified a number of issues 

that while not requiring legislation, could benefit from discussion in congressional 

report language or inclusion in an updated version of VHA Handbook 1200.17 which 

contains VA’s interpretation of the NPC statute and VA policy pertaining to NPCs. 

For example, NAVREF has included a recommendation for requiring VA to approve 

the establishment of a new NPC on the basis of an assessment of the ability of the 


wwoods2 on PRODPC68 with HEARING
67 

facility’s research or education program to generate a revenue stream sufficient to 

support the NPC infrastructure, and assurance that qualified staff will be available 

to manage the NPC. The NPC statute already states, ‘‘The Secretary may authorize 

the establishment at any Department medical center of a nonprofit corporation . . .’’ 

Therefore, no explicit statutory language is needed to give VA the ability to determine which facilities may establish new NPCs. However, it may be useful to include 

in report language a sense that there should be some minimum expectations of research programs contemplating establishing an NPC and then more specific policy 

guidance regarding the process of applying for VA approval could be provided in the 

handbook. This and a number of other recommendations will be provided to Congress as an addendum to NAVREF’s statutory proposal. We would be pleased to 

work with the Subcommittee to determine which the Subcommittee may wish to address in report language. 

Conclusion 

The NPCs represent a unique means for VA to maximize the benefits of externally 

funded research conducted in VA facilities. The NPCs are performing as Congress 

intended, serving as flexible funding mechanisms for the conduct of VA-approved research and education. NPCs facilitate research that benefits veterans, and they foster vibrant research environments at VA medical centers, enhancing VA’s ability to 

recruit and retain clinician-investigators and other staff who in turn apply their 

knowledge to state-of-the-art care for veterans. Some even contend that their NPCs 

and the contributions of services, personnel and equipment they provide in support 

of VA research have become an essential component of successful research programs. 

However, NAVREF recommends that in 2008, 20 years after the VA–NPC publicprivate partnership was first authorized, and co-incident with expiration of authority to establish new NPCs, it is time to update and clarify the NPCs’ enabling legislation. Experience working within the statute has brought to light its many 

strengths, but also areas that could benefit from updating and clarification, particularly in light of continuing evolution of VA health care and the increasing complexity of both research and nonprofit compliance. NAVREF would be pleased to 

work with the Subcommittee toward revisions in the statute that will allow NPCs 

to meet their full potential in supporting VA research and education while ensuring 

VA and congressional confidence in their management. 

Thank you for the opportunity to submit a statement for the record. If you have 

questions, please do not hesitate to contact NAVREF Executive Director Barbara 

West. 

f 

Statement of Orthotic and Prosthetic Alliance 

Mr. Chairman, thank you for the opportunity to submit this testimony on behalf 

of the Orthotic and Prosthetic Alliance (‘‘O&P Alliance’’). The O&P Alliance is a coalition of four of the primary organizations representing the field of orthotics (orthopedic braces) and prosthetics (artificial limbs). The four organizations include the 

American Academy of Orthotists and Prosthetists (‘‘AAOP’’), the National Association for the Advancement of Orthotics and Prosthetics (‘‘NAAOP’’), the American 

Orthotic & Prosthetic Association (‘‘AOPA’’), and the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (‘‘ABC’’). The O&P Alliance represents the professional, scientific, research, business, and quality improvement aspects within the fields of orthotics and prosthetics. 

Professional orthotic and prosthetic care combined with appropriate medical, surgical, and rehabilitative management provides the Veteran with limb loss and/or 

limb dysfunction the opportunity to live a highly functional life. The O&P Alliance 

would like to stress the importance of funding prosthetic and orthotic research and 

development. The past 30 years has seen great clinical and technological advancements in the orthotic and prosthetic fields. We have amputees and others with limb 

impairments to achieve unprecedented levels of function with the assistance of artificial limbs and orthopedic braces. The orthotic and prosthetic field must continue 

to advance in several areas to more accurately replicate human function and develop better measurement tools to assess quality and compare the relative effectiveness of orthotic and prosthetic interventions. 

Historically, the Department of Veterans Affairs (‘‘VA’’) has realized considerable 

success in conducting orthotic and prosthetic research. For example, the VA developed a method of fabricating a transparent plastic to assess the quality of prosthetic 


wwoods2 on PRODPC68 with HEARING
68 

socket fit in lower-limb amputees; the VA was among the first to design an energystoring and releasing prosthetic foot that spawned a new generation of far more responsive prosthetic feet for application to lower limb amputees with extensive mobility needs. The functional benefit of prosthetic feet of this design has been shown 

to reduce the walking fatigue and create a more fluid gait. The VA has also supported the adaptation of Computer Aided Design/Computer Aided Manufacture 

(CAD–CAM) to the field of prosthetics and orthotics, yielding significant new advancements and efficiencies in measurement, fitting, and fabrication of orthotics and 

prosthetics. 

Within the private sector of the organized field of orthotics and prosthetics we 

have seen many technological advancements that have become the standard of care 

for amputees and those with orthopedic impairments. The 1980’s and 1990’s were 

a time of significant industry investment in orthotic and prosthetic development 

that yielded many new advances achieving greater comfort, lighter weight, improved 

durability, and especially, increased function. It should be noted that the VA Prosthetic and Sensory Aids Service has adopted many of these advancements in O&P 

technology and routinely cover these technologies for veterans with orthotic and 

prosthetic needs. 

While technology has come a long way since the days of wooden legs and heavy 

metal braces, much remains to be done. To help plot a research agenda, the American Academy of Orthotists and Prosthetists has recently conducted a series of consensus conferences designed to prioritize such research. In addition, significant efforts have been undertaken in this area by the National Center for Medical Rehabilitation Research at the NIH. O&P technology research has also been supported 

by at least three other federal agencies, including the National Institute on Disability and Rehabilitation Research within the Department of Education, the National Science Foundation, and the Department of Defense. 

The pace of technological research and development has not been matched by the 

pace of outcomes research in the O&P field. The VA amputee population alone is 

widely disparate. It includes both aging and geriatric veterans who have become accustomed to more traditional technology, and newer, younger amputees returning 

from conflict abroad whose expectations for prosthetic rehabilitation are extremely 

high. In order to build on the successes the VA and the O&P field has had to date, 

it is necessary that the VA take into consideration that the patient population they 

serve is both growing and changing. We believe that these factors will make it vital 

for the VA to work more closely with the private sector to help lead the way for 

all users of orthotics and prosthetics, veterans and non-veterans, to benefit from 

continued research and quality care in this field. 

The demand for orthotic and prosthetic services continues to increase, not only 

from the influx of amputees and those with musculoskeletal injuries returning from 

combat abroad, but also from chronic disease at home. There are nearly 200,000 

members of the armed forces now in war zones who will be eligible for VA services 

as they leave the military. Young men and women returning from Iraq and Afghanistan may need VA services for the rest of their life. Diabetes, and the precursor to 

this chronic illness, obesity, are on the rise and are major contributors to amputation rates and other orthopedic conditions in this country. As the ‘‘baby boom’’ generation continues to age, the incidence and prevalence rates of orthopedic conditions 

will continue to increase significantly. 

For these reasons, there is a national need to improve the evidence base of prosthetic and orthotic care. Research is needed to develop better measurement instruments that will assist an orthotist or prosthetist with clinical decisionmaking and 

verify whether an orthotic or prosthetic intervention achieves a particular clinical 

goal. The ability to quantify functional outcomes will result in more accurate and 

clinically relevant cost-benefit analyses. These analyses, in turn, will enable more 

reliable quality of life studies as related to the application of new technologies currently being marketed directly to the public. 

Furthermore, research is needed to provide measurement tools for the practitioner 

to be able to assess performance of the orthosis and/or prosthesis and measure outcomes in environments outside the traditional clinic setting. It is difficult to utilize 

multi-center studies for orthotics and prosthetics due to the problems inherent in 

the inter-laboratory reliability of measurements involving gait laboratories. Research is needed to improve multi-center measurement reliability. In order to be statistically significant, this research should involve studies of sufficient size. 

The practice of orthotics and prosthetics is a very personal relationship between 

the patient and the practitioner. It is highly clinical and technical, and is for the 

remainder of the person’s life. The process of creating a complex treatment plan, coordinating treatment with the various medical and ancillary disciplines necessary 

for successful outcome is necessarily protracted. There are many steps in the process 


wwoods2 on PRODPC68 with HEARING
69 

requiring many appointments to achieve comfort, stability, and function. The end 

result is a melding of human flesh and man-made/designed hardware that is 

uniquely fit to meet the medical and functional needs of the patient, affording the 

Veteran the maximum degree of independence. The entire process is purely customized to the particular individual. As such, the practice of quality orthotics and 

prosthetics demands practitioner expertise and skilled technique which can vary 

considerably from practitioner to practitioner. There is a need for systems which can 

capture scientifically the subjective decisionmaking skills of practitioners recognized 

for their high level of expertise so that these skills can be shared more widely. When 

fully realized, the development of these tools and measurements will improve patient care across a broad spectrum of the public at a lower cost. 

To conduct effective evidence-based research, we believe it is imperative that 

there be a strong partnering between the VA and private sector O&P professionals 

who have potentially more current experience with such patients. Currently, many 

of the O&P services provided by the VA are performed under contract though private O&P practitioners. By teaming with the private sector on a comprehensive research agenda, the VA will be able to conduct more reliable research and serve all 

orthotic and prosthetic patients more effectively in the future. Considering the interests of the Department of Defense in providing quality orthotic and prosthetic care 

to wounded service men and woman, it stands to reason that DoD would also be 

a logical partner in this joint enterprise. 

We therefore propose that the VA and DoD fund a joint initiative with active involvement from the private sector to create a Prosthetic and Orthotic 

Outcomes Research and Treatment Center. Such a center would enable the 

military and VA health care systems to work with and alongside the civilian 

O&P profession to further develop the evidence base in the field. Such a center or network of centers could work cooperatively to further define common 

terms, refine functional measurement tools, conduct comparative studies of 

various technologies, and measure outcomes of prosthetic and orthotic interventions to clearly identify which treatment protocols are most effective. 

In this manner, patients would benefit from improved, evidence-based approaches 

to maximize their functional capacity. Health care payers (both military and civilian) would have additional data in which to base their coverage decisions and maximize their investment in prosthetic and orthotic services and the prosthetic and 

orthotic research community would be spurred into developments that are still on 

the horizon and improve education and training or O&P clinicians. 

Conclusion: 

The O&P Alliance appreciates the opportunity to testify on this very important 

issue. We urge the members of the Committee to continue to fund and conduct research in the areas of orthotics and prosthetics, and to work with the private sector 

to ensure that this research investment is optimized. We stand ready to work with 

this Committee to address these critical issues. Thank you for your consideration 

of our views. If you wish to discuss these issues further, please contact Peter W. 

Thomas, counsel to the O&P Alliance, at 202–466–6550. 

f 

Statement of Alvin C. Pike, CP, Lead Prosthetist 

Minneapolis, MN, Veterans Affairs Medical Center 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Congressman Michaud and members of the Subcommittee on Health, thank you 

for this opportunity to allow my statement to be a part of your proceedings. 

The views and opinions expressed are my own, and do not necessarily represent 

those of my current employer, the Department of Veterans Affairs, or those of the 

VA research community. They do however represent my 43 years as a prosthetist 

with a portion of that time in upper management with the world’s largest manufacturer of components for artificial limbs, and leadership offices within the prosthetics 

and orthotics profession. 

Today we see in the news media—brought about by the coverage given to amputees from Operation Enduring Freedom/Operation Iraqi Freedom—new high tech 

components for prostheses. An essential component to the success of this new technology is the man/machine interface that is called the socket. Although there have 

been numerous variations on socket design over the intervening half century, there 

have been no significant biomechanical studies of this integral portion of the prosthesis since research done at University of California Los Angeles in the fifties. Any 


wwoods2 on PRODPC68 with HEARING
70 

variations on basic designs have primarily come from the work of independent clinical prosthetists in private practices. 

In addition to socket design, I believe more research is needed on how the alignment of the components effect function, on socket suspension methods, and on the 

development of evidence based practice. 

In 2006, Northwestern University Rehabilitation Engineering Research Center in 

Orthotics and Prosthetics conducted an online forum followed by a meeting of 

prosthetists, orthotists, research engineers, and users of artificial limbs and braces. 

The report generated by this forum/meeting (attached) corroborates the pressing 

need for the type of research I have listed above. In fact, though virtually all participants agreed on the importance of research, most believed the current quantity of 

research to be insufficient. I believe this must be rectified to appropriately serve our 

veterans. 

The following is taken from: Prosthetics/Orthotics Research for the Twenty-first 

Century: Summary 1992 Conference Proceedings—John W. Michael, MEd, CPO, 

John H. Bowker, MD. 

‘‘The period from 1945–1965 is now viewed as a time of unparalleled scientific and technical advances in O&P. Key findings from this era still provide the conceptual basis for virtually all contemporary techniques. Although 

many factors have contributed to the long-term successes of this era, two key 

aspects were the coordination of research and evaluation efforts and the 

long-term commitment of significant governmental funding.’’ 

‘‘Although the field is currently in a relatively high state of clinical development, most advances in recent decades have been technical. Little or no 

advances in fundamental principles have occurred since the termination of 

significant governmental funding for O&P research and development in the 

sixties.’’ 

In closing I would like to quote the Hon. Anthony J. Principi from a speech given 

on November 17, 2003, in Arlington, Virginia. 

‘‘Good afternoon, and thank you for inviting me to help launch a new beginning for both VA’s orthopedic and prosthetics research and development, 

and for a brighter future for America’s disabled servicemembers and veterans, men and women who now bear the burdens of mid-20th century technology even as they live surrounded by the envelope pushing 

technologies of the 21st century.’’ 

Respectively submitted, 

Alvin C. Pike, CP 

(Board Certified Prosthetist) 

Past President—American Academy of Orthotists and Prosthetists 

Attachments: NU State of the Science Report [The attachment is being retained in 

the Committee files.] 

f 

Statement of Hon. John T. Salazar 

a Representative in Congress from the State of Colorado 

Thank you Mr. Chairman for an opportunity to discuss the important issues of 

VA Research programs. 

I would like to especially thank our witnesses this morning for their commitment 

to our troops. 

We have made such advancements in the field of medicine that the likelihood of 

dying on the battlefields today is less than in previous wars. 

This is the reality. However we’ll never be able to turn those advancements into 

real life benefits for our men and women in uniform without the proper funding. 

Earlier this year during the budget process, the Administration requested $411 

million for FY 2008, a decrease of $2.7 million below FY 2007 levels. 

This Committee recommended $452 million, a $38.3 million increase above FY 

2007 levels, and $41 million above the VA’s request. 

Research is one of the core missions of the Veterans Health Administration, and 

we’re committed to providing the resources necessary to accomplish that mission. 

This Committee, and this Congress, have made a promise to care for our veterans, 

and fighting for proper funding is part of that promise. 

f 


wwoods2 on PRODPC68 with HEARING
71 

POST HEARING QUESTIONS AND RESPONSES FOR THE RECORD: 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 11, 2007 

Joel Kupersmith, M.D. 

Chief Research and Development Officer 

Veterans Health Administration 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Dr. Kupersmith: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans Affairs Subcommittee on Health at the hearing on ‘‘VA Research Programs’’ held on October 4, 2007. 

Please provide answers to the following questions by November 26, 2007. 

1. Infrastructure 

• As the VA moves forward with construction of new hospitals, what types of 

infrastructure should be incorporated into these facilities in order to support 

research activities? • How specifically does aging infrastructure impact the VA’s ability to conduct 

research? 

2. Collaboration With Other Departments 

• How does the VA partner with other agencies (DoD, HHS) in research? • What can the VA do to work more effectively with other agencies to do research and to share resources and information—to ultimately benefit veterans? 

3. Phantom Limb and Stump Pain 

• What specific research projects does the VA have to address the issue of 

phantom limb and stump pain? What future plans does the VA have to conduct research on this issue? 

4. Eye Trauma 

• How many OEF/OIF veterans are returning with eye problems? • What is the VA currently doing in terms of eye research? What types of research is planned for the future to help these veterans? 

5. Research Priorities 

• What should be the VA’s top 3 research priorities? 

• Do you see these priorities changing over the next 10 years? 20 years? If so, 

how? 

6. Barriers to Collaboration 

We have heard from several sources that there are barriers to the VA getting 

research money agencies such as NIH and NIMH. 

• Can you please comment on this issue? What is the nature of these barriers? 

• What can the VA do to make it easier for it to get research money from 

these agencies? 

7. Intellectual Property 

There has been some discussion recently about VA research and intellectual 

property—who owns the research. 

• Can you please comment on this issue? 

• How does the intellectual property issue affect the availability of the most 

current medical treatment to veterans? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by November 26, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 


wwoods2 on PRODPC68 with HEARING
72 

Questions for the Record 

Hon. Michael Michaud, Chairman 

Subcommittee on Health House Veterans’ Affairs Committee 

October 4, 2007 

VA Research Programs Hearing 

Infrastructure 

Question 1: As the VA moves forward with construction of new hospitals, what 

types of infrastructure should be incorporated into these facilities in order to support research activities? 

Response: Most research within the Department of Veterans Affairs (VA) is carried out by researchers who are affiliated with medical schools or other institutions 

of higher learning. In general, a decision to include research space within a new VA 

facility depends upon the strength of the current VA and academic affiliate research 

efforts (in the case of replacement facilities), or on the research potential of the academic affiliate (in the case of new facilities). In general, it is not a prudent use of 

resources to build research infrastructure at a VA hospital in the absence of a 

strong academic affiliate or nearby Federal laboratory. 

In those facilities where establishment of a research program is appropriate, such 

as those affiliated with top medical schools, it is critical that it be built for flexible 

long-term use. Current laboratory research requires laboratories which are readily 

reconfigured to meet new research demands. This generally requires more electrical 

power, better ventilation and more plumbing than are found in older laboratories 

or in less expensive ‘‘fixed’’ laboratory designs. Such laboratories are likely to be appropriate for state-of-the-art genomic and physiologic research. Facilities may need 

specially configured rooms for modern human and animal imaging equipment, including magnetic resonance imaging systems and microscopes, computed tomographic scanners and the like. Similarly, construction of flexible animal facilities 

that are capable of providing humane care for a variety of species ranging from rodents to primates is advisable. Engineering laboratories that are capable of fabricating prosthetic devices as well as microelectromechanical systems facilitate research efforts to restore function to veterans suffering traumatic injuries in war. 

State-of-the-art clinical research units facilitate the translation of basic research 

findings into life-saving and life-enhancing medical treatments. All require information technology support which is both state-of-the-art and specific to the research 

undertaken in an individual facility. 

Question 2: How specifically does aging infrastructure impact the VA’s ability to 

conduct research? 

Response: Aging infrastructure at some VA facilities negatively impacts VA’s 

ability to conduct research by impeding the recruitment of new investigators, who 

are often put-off by aging facilities. Inadequate electrical supplies and ventilation 

makes it difficult to support state-of-the-art research equipment, making it both 

more difficult for investigators to compete for scarce VA and National Institutes of 

Health (NIH) research funding, and more difficult to carry out uniquely VA research 

aimed at improving the physical and mental health of those suffering injury during 

military service. In spite of these limitations, however, VA researchers continue to 

carry out world-class laboratory and clinical research which is published in top journals such as Science, Nature and The New England Journal of Medicine. This research improves the health of veterans and often that of the general public and is 

America’s most cost-effective medical research investment. 

Collaborations With Other Departments 

Question 3: How does the VA partner with other agencies (DoD, HHS) in research? 

Response: Through VA’s academic affiliations and collaborations with other entities, VA research is fully integrated with the larger biomedical research community. 

VA scientists partner with colleagues from other Federal agencies [e.g., the Department of Defense (DoD) and the National Institutes of Health (NIH)], academic medical centers, non-profit organizations and commercial entities nationwide to further 

expand the reach and scope of VA research. Partnering and coordinating is accomplished at both the national and local levels. At the national level, VA scientific program managers work closely with their colleagues in other agencies to develop joint 

solicitations, identify partnering opportunities, review programs to eliminate redundancy and establish mechanisms such as joint scientific conferences to keep our research at the cutting edge. Additionally, national program staff enlist scientists from 


wwoods2 on PRODPC68 with HEARING
73 

DoD, NIH, other Federal agencies and academia to participate on peer review panels of VA research, and assist in finding VA scientists to serve on the peer review 

panels of other agencies. On the local level, VA scientists collaborate extensively 

with other agencies through collaborative research projects, intergovernmental personnel agreements, memoranda of understanding, interagency workgroups and 

other mechanisms. 

Question 4: What can the VA do to work more effectively with other agencies 

to do research and to share resources and information—to ultimately benefit veterans? 

Response: VA is currently implementing NIH’s electronic research administration (eRA) system for the submission, review and tracking of research proposals submitted by VA investigators. By sharing a common platform and database for research, scientific program managers in VA and other agencies can better coordinate 

scientific efforts. Additionally, VA’s Office of Research and Development (ORD) is 

working with VA’s Office of Information and Technology and other Federal agencies 

to develop secure systems for data sharing and exchange. 

Phantom Pain and Stump Pain 

Question 5: What specific research projects does the VA have to address the 

issue of phantom limb and stump pain? What future plans does the VA have to conduct research on this issue? 

Response: VA’s ORD supports a growing portfolio in pain-related research. VA 

investigators are examining the complexities of pain and how best to ameliorate its 

disabling effects among veterans, including those with phantom limb pain, as well 

as pain related to the residual limb, spinal cord injury, multiple sclerosis, osteoarthritis, back disorders and other conditions. 

Basic research is aimed at understanding the underlying molecular basis for pain, 

while applied work is examining traditional pharmacologic means and interventions 

such as cognitive behavioral therapy. It is anticipated that discoveries from these 

projects will provide information in pain management and underlying sources of 

pain. 

In one exciting recent study, VA investigators identified specific channels responsible for conveying pain signals to the brain (Nature. 2006; 444(7121):831–832). VA 

researchers are exploiting this finding to develop new pain treatments. 

In other ongoing projects, VA researchers are conducting imaging studies to identify and examine sources of pain; investigating enhancements to pain control from 

conservative therapy, including oral and topical analgesics, to corticosteroid injections, electrical stimulation and socket reshaping; and examining the effectiveness 

of exercise (e.g., strengthening, flexibility-enhancing and cardiovascular enhancements) to ameliorate pain. 

VA’s research program plans to expand on its current pain research initiatives to 

develop novel therapies to address pain, develop new ways to improve coping strategies and rehabilitative outcomes and test new paradigms of pain assessment, management and treatment. 

Eye Trauma 

Question 6: How many Operation Enduring Freedom/Operation Iraqi Freedom 

(OEF/OIF) veterans are returning with eye problems? 

Response: Since the majority of the eye injuries requiring eye surgery are cared 

for by military (DoD) ophthalmologists prior to release from active duty, DoD would 

be the appropriate source for comprehensive data related to eye injuries or traumatic brain injury (TBI) suffered in OEF/OIF combat and any vision loss resulting 

from those injuries. VA Eye Care Services is collaborating with DoD to develop a 

database related to eye injuries and TBI related vision loss. 

VA does have data on OEF/OIF patients who have received rehabilitation services 

in the VA blind rehabilitation centers. In July 2007, data from President’s Commission on Care for America’s Returning Wounded Warriors indicated that 48 OEF/OIF 

veterans had been treated by VA blind rehabilitation centers; as of October 2007, 

53 OEF/OIF veterans were admitted for treatment. 

Question 7: What is the VA currently doing in terms of eye research? What types 

of research are planned for the future to help these veterans? 

Response: VA’s ORD supports a broad portfolio of vision-related research seeking 

to improve everyday function and quality of life among veterans suffering from vision loss, whether from acute trauma or due to age-related changes. Research extends from practical aspects of way-finding (i.e., maneuvering in the environment) 


wwoods2 on PRODPC68 with HEARING
74 

to the development of advanced intraocular transplants. Several individual research 

projects and two centers of excellence (Aging Veterans with Vision Loss; Innovative 

Visual Rehabilitation) focus on the rehabilitation of low-vision and blind veterans. 

VA supported research has led to measurement tools such as the VA Low Vision 

Visual Functioning Questionnaire (long and short form) that is used in clinical practice to measure functional ability of low vision patients and to measure patient-centered outcomes of low vision rehabilitation. This questionnaire is used in both VA 

and non-VA clinics. 

Current work involves advanced orientation and way-finding technologies for low 

vision and blind veterans to allow them to navigate independently in various environments. This includes the use of talking Braille signs, global positioning systems 

and virtual reality training systems to use in rehabilitation activities. Work is also 

under way to develop a retinal implant (type of neuroprosthesis) to restore vision 

to the blind. 

Future planned research includes visual robots for orientation and way-finding of 

low vision and blind veterans; further development of retinal implant technology; 

and rehabilitation strategies for veterans with dual sensory impairment (vision and 

hearing), which is occurring due to trauma, as well as age-related phenomena. 

Research Priorities 

Question 8: What should be the VA’s top 3 research priorities? 

Response: It is crucial that VA’s research programs remain focused on veterans’ 

high priority healthcare needs. The quality of the research and relevance to the veteran population remain the determining factors in deciding what studies to fund. 

The top three priority areas for VA research include: 

• The needs of returning OEF/OIF veterans, including TBI and other 

neurotrauma, such as sensory loss and spinal cord injury; post-deployment mental health, including post-traumatic stress disorder and depression; prosthetics 

and amputation healthcare; pain; polytrauma (i.e., complex, multiple traumas); 

and access to care for OEF/OIF veterans; 

• The needs of the aging veteran population, particularly treatments for chronic 

diseases; and 

• Personalized medicine, meaning increasing our understanding of the role of genetics and other individual issues in diagnosis and treatment of illnesses to 

allow VA to provide care that is tailored specifically to the makeup of individual 

veterans. VA is uniquely positioned to lead in this area because of its large patient population that is stable, diverse and treated in a variety of settings, care 

system with outstanding investigators and an integrated research network and 

unrivaled electronic health record. 

Question 9: Do you see these priorities changing over the next 10 years? 20 

years? If so, how? 

Response: Because the mission of VA research is to improve veterans’ lives, our 

priorities will adapt as the needs of veterans change. Although we cannot predict 

all those needs for the future, we do rely on projections in the veteran population 

as well as trends in medical research and medical care. It is certain that VA research will need to increasingly address the needs of OEF/OIF veterans, including 

the long-term outcomes of post-traumatic stress disorder (PTSD), TBI and other 

blast injuries, which are creating the types of complex co-occurring illnesses previously limited to elderly. OEF/OIF TBI veterans may have a life expectancy of 50 

years or more, so their health and care-giving needs are considerable. Additionally, 

as the demographics of the military change (e.g., increased women veterans and minority veterans) our research will adapt to address their unique issues. 

We also anticipate by changing the expectation of veterans and their caregivers, 

VA research will be prompted to create innovations that promote more personalized, 

community-based options for care. Rapid learning and needs assessment using improved tools for ‘‘data mining’’ the personalized health record is a critical strategy 

for the next 10 years and beyond. 

Finally, based on recent and projected advances in our understanding of biological 

systems underlying illness, we anticipate that genomics and related research will 

play an increasingly larger role in VA’s research portfolio. Genomic medicine has 

the potential to significantly improve the quality of care for veterans, especially in 

the treatment of chronic diseases. Recent research findings have shown that 

genomic medicine shows great promise to prevent adverse drug reactions, personalize clinical care, customize drug treatments and improve outcomes. 


wwoods2 on PRODPC68 with HEARING
75 

Barriers to Collaboration 

We have heard from several sources that there are barriers to the VA getting research money from agencies such as NIH and NIMH. 

Question 10: Can you please comment on this issue? What is the nature of these 

barriers? 

Response: VA investigators have, in fact, been successful in competing for and 

receiving increased funding from the NIH and other Federal research sponsors over 

the past several years. Much of this funding is administered by academic affiliates 

or by VA-affiliated nonprofit research and education corporations (NPC) which provide a flexible funding mechanism for the administration of non-VA funds. 

While there are no statutory or regulatory barriers to VA obtaining research 

funds from NIH and other Federal agencies and administering them through academic affiliates or NPCs, there are some administrative barriers. Currently, a limited number of NPCs administer Federal funds, and many lack the resources and 

expertise needed to do so. Dual-appointment researchers (i.e., VA and academic affiliate) generally have its Federal funds administered through the university, but 

the few VA researchers without university appointments do not have this option. 

Question 11: What can the VA do to make it easier for it to get research money 

from these agencies? 

Response: VA is currently working on solutions regarding the administration of 

federal funds by NPCs, including consolidation and training. 

Intellectual Property 

There has been some discussion recently about VA research and intellectual property—who owns the research. 

Question 12: Can you please comment on this issue? 

Response: If intellectual property (IP) is created in the course of VA research, 

VA may assert ownership of the IP and file patent applications, as appropriate, or 

pursue other means of protecting and encouraging the development of the research 

discovery. The decision to assert ownership depends on the presence and degree of 

VA contribution, including facilities, funds, information, equipment, materials and 

employee time. 

Because most VA investigators have dual appointments with an academic affiliate, one or more university partners may also assert ownership to VA intellectual 

property. To address this unique relationship and to facilitate cooperation between 

the VA and academic affiliates, VA developed a Cooperative Technology Administration Agreement (CTAA). This legal agreement outlines relevant definitions, terms 

and conditions for managing the intellectual property, and allows the joint owners 

to work as one decisionmaking body in the best interest of technology transfer and 

development. The CTAA preserves VA ownership, while granting the university the 

necessary authority to protect and market the IP. 

If IP is created in the course of privately sponsored VA research, VA maintains 

ownership of all data and IP emerging from these agreements. The sponsor often 

is granted an up front, non-exclusive license to IP resulting from the study. 

Question 13: How does the intellectual property issue affect the availability of 

the most current medical treatment to veterans? 

Response: It generally has no effect because discoveries that emerge from VA research are typically in an early stage of development, requiring further reduction 

to practice, validation and scale-up before they can provide any benefit to veterans. 

This development work is generally beyond the scope and mission of VA, so a commercial partner who is willing to commit considerable resources and assume significant risk is needed. Patents allow the commercial partner to take the development 

risk with some promise of financial return. 

The VA currently is reviewing several allegations of patent infringement in which 

the patent owners allege that their inventions are used or manufactured by or for 

VA without license of the owner thereof. The technologies range from cardiovascular 

stents to hearing aids. If the allegations are proven, the ultimate costs of providing 

such devices to veterans may increase. However, a perfected government use license 

acquired in consideration of VA contributions may be offered as a defense. 

f 


wwoods2 on PRODPC68 with HEARING
76 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 5, 2007 

Honorable Gordon Mansfield 

Acting Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Mansfield: 

On Thursday, October 4, 2007, Dr. Joel Kupersmith, MD, Chief Research and Development Officer, Veterans Health Administration, testified before the Subcommittee on Health on the U.S. Department of Veterans Affairs Research Programs. As a follow-up to the hearing, I request that Dr. Kupersmith respond to the 

following questions in written form for the record: 

1. Please list the number of invention patents VA has processed, retained ownership rights, and retained sole ownership rights since VA’s Technology Transfer 

Program was established in 2000. Additionally, provide an estimate of the 

number of ‘‘lost opportunities’’ and the reason the Department did not pursue 

these opportunities. 

2. Please explain the mechanisms of joint patents filed by VA with its academic 

partners. Specifically, how are respective ‘‘contributing shares’’ determined? Assuming the subsequent licensing of those patents, how are royalty distributions 

between partners determined? Are royalty distributions received by the VA 

under those circumstances, in force over the life of the patent, or are VA’s royalties received in one lump sum? 

3. What are some challenges VA faces in deploying the latest state-of-the art 

prosthetics research into prosthetic care for veterans? 

4. What collaborative activities are VA and the U.S. Department of Defense 

(DoD) currently conducting? Is there a Memorandum of Agreement or Memorandum of Understanding between VA and DoD for collaborative research? 

What about for other federal departments? 

5. How do VERA funds support VA research? Are such funds actually received 

by the medical center, and in the research laboratory? How does VA know this 

to be the case? What monitors does VA use to ensure these funds are allocated 

to research? 

6. Has VA completed its study to identify deficiencies in VA’s research infrastructure? Has VA developed a prioritized plan to renovate and modernize VA research infrastructure? If so, please provide a list of the prioritized research facility projects and include the cost of the project and implementation timeline. 

7. What training does VA provide researchers on VA Data Security and Privacy 

policies? How is this training verified and tracked? How many VA researchers 

have not received the training? Does VA require encryption for all researchers 

accessing VA data? 

8. The Office of Inspector General has released a number of reports recently on 

problems with researchers operating outside the scope of practice. What steps 

is VA taking to ensure that researchers are acting within their scope of practice? Does VA believe that a researcher operating outside their scope of practice constitutes a violation of human subjects protections? How are researchers 

trained on human subjects protections? Is this training documented? How often 

is this training provided? 

The attention to these questions by the witnesses is much appreciated, and I request that they be returned to the Subcommittee on Health no later than close of 

business, 5:00 p.m., Friday, November 2, 2007. If you or your staff have any questions, please call Dolores Dunn, Republican Staff Director for the Subcommittee on 

Health, at 202–225–3527. 

Sincerely, 

Jeff Miller 

Ranking Member 


wwoods2 on PRODPC68 with HEARING
77 

Questions for the Record 

The Honorable Jeff Miller, Ranking Republican Member 

Subcommittee on Health 

House Committee on Veterans’ Affairs 

October 4, 2007 

VA Research Programs 

Question 1: Please list the number of invention patents VA has processed, retained ownership rights, and retained sole ownership rights since VA’s Technology 

Transfer Program was established in 2000. Additionally, provide an estimate of the 

number of ‘‘lost opportunities’’ and the reason the Department did not pursue these 

opportunities. 

Response: Since 2000, the Department of Veterans Affairs’ (VA) Technology 

Transfer Program (TTP) has received 1,226 invention disclosures. VA retained 

rights to 744 of these inventions. Of those inventions, 69 are solely owned by VA. 

Each of VA’s inventions has undergone a commercial and patentability assessment by either VA or the academic affiliate. As such, VA’s TTP has taken advantage 

of all opportunities on those inventions disclosed since the program was established 

in 2000. The commercial and patentability assessment can include discussions with 

the VA inventor, patentability opinions from VA contract patent attorneys and technology assessments from marketing contractors. VA has marketed all its inventions 

in hopes of finding a licensee or a cooperative research and development partner to 

advance the technology and bring it to market. 

Question 2: Please explain the mechanism of joint patents filed by VA with its 

academic partners. Specifically, how are respective ‘‘contributing shares’’ determined? Assuming the subsequent licensing of those patents, how are royalty distributions between partners determined? Are royalty distributions received by the 

VA under those circumstances, in force over the life of the patent, or are VA’s royalties received in one lump sum? 

Response: Most VA investigators have dual appointments with an academic affiliate. This often results in co-ownership of an invention between VA and the academic affiliate. To address this unique relationship and facilitate and enhance the 

cooperation between VA and academic affiliates, VA developed a cooperative technology administration agreement (CTAA). This agreement outlines relevant definitions, terms and conditions for handling co-owned intellectual property (IP). Using 

the CTAA preserves VA ownership while providing the university the needed authority to effectively patent and market the IP. The ClM also has a provision that 

if the university chooses not to patent or market an invention VA has the right to 

do so. Currently, VA has executed 76 ClMs with some of the leading research institutions in the country, including Harvard, Yale, Stanford and the entire University 

of California system. 

VA’s ‘‘contributing shares’’ are calculated in terms of the number of VA inventors 

as a proportion of the total number of inventors. For example, if an invention has 

two inventors, one full-time VA staff and one non-VA university staff, the ‘‘net revenue’’ split would be 50 percent to VA and 50 percent to the university. 

‘‘Net revenue’’ is defined as total revenue, minus royalties paid to the inventors, 

expenses (e.g., patent filing costs) and a 15 percent administrative fee. All net revenues are to be paid annually over the life of the patent or for the term specified 

in the license. 

Question 3: What are some challenges VA faces in deploying the latest state-ofthe-art prosthetics research into prosthetic care for veterans? 

Response: New and emerging technology (e.g., bionics, microprocessors and electric and myoelectric components) is becoming commercially available at a very quick 

pace. In addition, manufacturers make claims and develop criteria about new products for which there is very little scientific or clinical evidence. We have in the past 

worked with researchers and developers on new and emerging technologies in clinical settings, where we have fit a variety of new devices over the years. Some examples include: Advanced Body Powered Arm; Synergetic Prehensor; Modular Electronic Locking/Unlocking Actuator (for elbow); and the Hypobaric Lower Limb Suspension Systems. It is critical that VA continue to evaluate these new products in 

the process, and develop criteria by consulting with clinicians and researchers specializing in new and emerging technology. 

Question 4: What collaborative activities are VA and the U.S. Department of Defense (DoD) currently conducting? Is there a Memorandum of Agreement or MemoVerDate Aug 31 2005 00:21 Jul 17, 2008 Jkt 039459 PO 00000 Frm 00081 Fmt 6604 Sfmt 6621 E:\HR\OC\A459.XXX A459

wwoods2 on PRODPC68 with HEARING
78 

randum of Understanding between VA and DoD for collaborative research? What 

about for other federal departments? 

Response: In the context of research, VA’s Office of Research and Development 

(ORD) has a long history of collaboration with DoD and collaboration has substantially increased over the last 2 years. Individual research projects currently under 

way are examining a wide range of topics, including traumatic brain injury (TBI), 

polytrauma, prosthetics and amputation healthcare, post-traumatic stress disorder 

(PTSD) and other post-deployment mental health, burns and pain. 

High-level planning and coordination of research efforts in response to the needs 

of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans began 

in May 2006, with an interagency workgroup planning conference that mapped the 

landscape of post-deployment mental health issues. The conference report is available at: www.research.va.gov/news/announcements/deployment-meeting.cfm. This 

planning conference led to an inter-agency solicitation for research proposals. 

A subsequent senior leadership meeting held at Fort Detrick, MD, on November 

13, 2006, articulated further principles for collaboration and identified TBI and 

PTSD as key topics for coordinated effort. 

ORD scientific leadership participated June 11–13, 2007, in a DoD-sponsored 

PTSD/TBI vision setting meeting, in which plans were articulated for the use of the 

$300 million supplemental appropriation received by Defense Health Programs for 

PTSD and TBI research. Senior ORD scientific staff continues to work closely with 

the DoD’s Congressionally mandated medical research programs to implement the 

$300 million supplemental appropriation in support of PTSD and TBI research. It 

is anticipated that VA researchers will submit proposals and collaborate extensively 

with their DoD counterparts in this Congressionally directed initiative. 

In addition, ORD is currently planning, in collaboration with DoD investigators, 

a state-of-the-art conference on OEF/OIF-relevant research, which will be presented 

to a joint VA/DoD audience in the spring of 2008. 

Furthermore, VA and DoD regularly involve each other in the evaluation of research proposals and funding selections. 

Memoranda of Understanding exist between VA and DoD, as well as other Federal departments, for specific research projects. 

Question 5: How do VERA funds support VA research? Are such funds actually 

received by the medical center, and in the research laboratory? How does VA know 

this to be the case? What monitors does VA use to ensure these funds are allocated 

to research? 

Response: The Veterans Equitable Resource Allocation (VERA) allocates research 

support funds based on the total expenditures of funded research at each medical 

center. These expenditures are weighted based on whether the research is administered by VA or is peer reviewed. The total amount allocated in VERA is based on 

the estimates for medical care support to research as submitted in the President’s 

medical programs budget request. 

Networks distribute to medical centers research support funds as they are computed for each medical center, care line or product line. Each medical center, care 

line or product line explicitly accounts for, and obligates, research support funds to 

support the salaries of clinician-researchers, and research facilities and administrative costs. Research support expenditures are monitored on the local level by administrative officers for research, working in partnership with facility fiscal staff. 

Question 6: Has VA completed its study to identify deficiencies in VA’s research 

infrastructure? Has VA developed a prioritized plan to renovate and modernize VA 

research infrastructure? If so, please provide a list of the prioritized research facility 

projects and include the cost of the project and implementation timeline. 

Response: VA’s Office of Research and Development has established a research 

infrastructure evaluation and improvement project to review VA’s research facilities 

and identify deficiencies. 

A detailed questionnaire regarding current research space allocation and condition 

was disseminated to all field sites to gather preliminary information. Preliminary 

results showed a need for research infrastructure corrections across the system. To 

better document and prioritize issues identified in the preliminary assessment, a 

comprehensive evaluation instrument designed to ensure a thorough and consistent 

system-wide review of research space was developed and tested at three pilot sites. 

A summary of the three pilot surveys completed will be provided in a report to Congress in the near future. 

In addition, VA recently selected a contractor to complete the research facility site 

visits. Three site visits were conducted in September 2007. Over the next 3 years, 


wwoods2 on PRODPC68 with HEARING
79 

approximately 70 more site visits will be conducted. VA plans to issue reports to 

Congress periodically, as appropriate, describing the efforts undertaken. 

Because the research infrastructure evaluation and improvement project is still 

under way, a prioritized list of research facility projects is not available. 

Question 7: What training does VA provide researchers on VA Data Security and 

Privacy policies? How is this training verified and tracked? How many VA researchers have not received the training? Does VA require encryption for all researchers 

accessing VA data? 

Response: All staff involved in VA research, not just researchers, are required 

to take the course VA Research Data Security and Privacy. This includes all VA research office personnel, researchers, study coordinators, research assistants, trainees such as house officers and students, administrative support staff (including secretaries and clerks) and members of the Institutional Review Board (IRB) and Research and Development Committee. Personnel includes compensated and without 

compensation employees and those on Intergovernmental personnel agreements 

(IPAs). Local VA facilities must maintain documentation that training requirements 

have been met. 

As of October 12, 2007, 20,929 people have taken the course since VA began offering it in February 2007. Data does not exist on how many researchers have not 

taken the course. 

In addition, all Veterans Health Administration (VHA) staff are required to take 

the VA Cyber Security Awareness Training Course and the VHA Privacy Policy 

Training Course. 

VA Handbook 6500 requires that VA sensitive information, including sensitive research data, must be in a VA protected environment at all times or it must be 

encrypted. All portable media (e.g., laptops, portable drives, thumb drives, compact 

discs) that contain VA sensitive information must be encrypted. 

Question 8: The Office of the Inspector General has released a number of reports 

recently on problems with researchers operating outside the scope of practice. What 

steps is VA taking to ensure that researchers are acting within their scope of practice? Does VA believe that a researcher operating outside their scope practice constitutes a violation of human subjects protections? How are researchers trained on 

human subjects protections? Is this training documented? How often is this training 

provided? 

Response: VA’s Office of Research and Development (ORD) requires a scope of 

practice for researchers and staff working on human subjects research protocols. 

The scope of practice is based on the occupational category under which the person 

is hired and the person’s qualifications, including licensure and training. In addition, the scope of practice is agreed upon by the person’s immediate supervisor and 

the associate chief of staff for research and development. 

Each VA facility is responsible for the credentialing of all research employees and 

the local research office ensures that this is done and that a scope of practice has 

been developed. The principal investigator for each protocol is responsible for all aspects of that research and, as such, ensures that the research staff is qualified to 

perform their duties and that the duties are consistent with the scope of practice. 

Working outside of a scope of practice may or may not represent harm to subjects. 

It depends on the specific task or procedure that was conducted and the specific research protocol. Working outside the scope of practice may also violate other Federal 

and State laws such as practicing medicine without a license. 

All staff involved in VA human research (except secretarial support staff) is required to have annual training in good clinical practices and the ethical principles 

of human research protection. Most individuals meet this requirement by taking the 

same online Collaborative Institutional Review Board Training Initiatives (CITI) 

course used by many academic institutions. If VA facilities obtain permission from 

ORD, they may substitute other comparable training (e.g., in person courses that 

cover the material). CITI keeps electronic records of everyone who completes the 

course. This is an annual training requirement. 

Æ 


wwoods2 on PRODPC68 with HEARING