individuals with severe combat-related injuries. Together, the
DoD and VA launched efforts to create these systems by
both building upon existing resources and acquiring new
capabilities in partnerships with academic institutions, veteran
service organizations, industry, and other federal agencies.
DoD Clinical Care
In 2001, the U.S. Army designated Walter Reed Army Medical
Center, now Walter Reed National Military Medical Center
(WRNMMC), as the
flagship location to provide extremity
trauma and amputee care for the U.S. military. In 2003, the
U.S. Army established the Armed Forces Amputee Patient
Care Program to provide state-of-the-art surgical and rehabil-
itative care to patients with limb loss.
3
This program lever-
aged resources and subject-matter experts across the Military
Health System to optimize patient outcomes. By 2007, the
DoD had established three state-of-the-art Advanced Reha-
bilitation Centers (ARCs) to provide clinical rehabilitative
care services and promote a return to high-level function: the
Military Advanced Training Center (MATC) at WRNMMC,
the Center for the Intrepid at San Antonio Military Medical
Center (SAMMC), and the Comprehensive Combat and
Complex Casualty Care (C5) Program at the Naval Medical
Center San Diego. These DoD ARCs continue to deliver
coordinated, patient-centered care and management through
interdisciplinary teams.
4
VA Clinical Care
The VA health care system has well-established clinical
rehabilitation programs for veterans experiencing a myriad
of disabling conditions, including spinal cord injury, neuro-
degenerative diseases, mental health conditions, stroke, brain
injury, low vision/blindness, and limb loss. While the major-
ity of all veterans with amputation experienced new limb
loss secondary to vascular disease and diabetes, the VA pro-
vides a lifelong continuum of care for patients with both
disease- and trauma-related amputation.
5
As a result of injuries
suffered during OEF/OIF/OND, there was an increase in the
number of veterans with combat-related limb loss seen by the
VA. Of those, 50% also sustained concomitant traumatic
brain, peripheral nerve, spinal cord, soft tissue, and/or psy-
chological injuries such as post-traumatic stress disorder.
6
This combination of multiple injuries resulting from the
same traumatic event was termed
“polytrauma” by the VA
for the purpose of de
fining the system of care services that
would be needed as combat operations continued.
7
Public
Law 108
–422, also known as the Veterans Health Programs
Improvement Act of 2004, charged the VA to create
“centers
for research, education, and clinical activities on complex
multi-trauma associated with combat injuries.
”
8
In 2005, the
Polytrauma System of Care (PSC) was established in con-
junction with the designation of four Polytrauma Rehabili-
tation Centers (PRCs). The PSC is an integrated network
of specialized rehabilitation programs dedicated to serving
veterans and service members with both combat- and civilian-
related traumatic brain injury and polytrauma injuries, includ-
ing limb loss.
In 2008, emulating the PSC model, the VA established
an Amputation System of Care (ASoC). The ASoC is com-
mitted to delivering a full range of amputation care and
rehabilitation services, including use of telehealth technolo-
gies, to more than 80,000 veterans who have sustained an
amputation.
9
The ASoC consists of a hub-and-spoke system
made up of 4 care components: 7 Regional Amputation
Centers (RACs), 18 Polytrauma Amputation Network Sites
(PANS), 108 Amputation Care Teams (ACTs), and Amputa-
tion Points of Contact (APoC) across the United States and
Puerto Rico.
5
DoD-VA Research Scope and Partnerships
The need for innovative surgical and rehabilitation technolo-
gies and treatment strategies increased exponentially because
of severe injuries sustained by service members throughout
recent con
flicts. In response to this demand, research pro-
grams within the DoD and VA redirected efforts toward car-
ing for the combat wounded. These programs broadened
their research scope to include traumatic brain injury, blast-
related sensory loss, amputation, polytrauma, and the devel-
opment of advanced prosthetics for combat-injured service
members. These efforts were not performed in isolation
—
multiple partnerships and collaborations across federal agen-
cies, academic institutions, and industry were created and/or
expanded to address growing clinical needs. The DoD and
VA increased collaborative efforts in many clinical research
areas and coauthored a
“guidebook” that provides sugges-
tions for identifying collaborators with common research
goals, summarizes administrative and funding mechanisms,
and identi
fies procedures for establishing collaborations.
10
DoD Research Support
One core source of research support within the DoD is
the U.S. Army Medical Research and Materiel Command
(USAMRMC) Congressionally Directed Medical Research
Programs (CDMRP), which provides Defense Medical
Research and Development Program (DMRDP) execution
management support for the six Defense Health Program
core research program areas ($452.6 million
fiscal year [FY]
2010
–2015, estimated $299.6 million FY 2016).
11
Each
major research program area is guided by a Joint Program
Committee (JPC) comprised of DoD and non-DoD medical
and military technical experts who translate guidance into
research and development needs. They also have key respon-
sibilities for making funding recommendations and provid-
ing program management support.
The EACE research efforts are most closely aligned with
Joint Program Committee-8/Clinical and Rehabilitative Medi-
cine Research Program (JPC-8/CRMRP), which seeks to
find,
evaluate, and fund cutting-edge research in reconstruction,
MILITARY MEDICINE, Vol. 181, November/December Supplement 2016
4
EACE: Overview of the Research and Surveillance Division