Wounded Warrior Project. 10 Years: a decade of service - a lifetime of commitment

Objective 3: Optimal, Long-term Rehabilitative Care - Initiative 3

Improving the effectiveness of the VA’s amputee care.

Improved protective gear, rapid medical evacuation, and innovations in military trauma medicine help account for a nearly 90 percent survival rate among those injured in Iraq and Afghanistan.168 But with less protected extremities, our warriors have experienced major limb loss – many with multiple amputations -- and a need for extensive rehabilitation.   The long road to recovery and rehabilitation has both physical and psychological dimensions, but excellent prosthetic care is critical.

Just as our warriors are adapting to life-changing injuries, the war has severely challenged the health care systems on which they depend.   The VA, particularly, with its generally older patient population whose prosthetic needs are most often linked to diabetes and post-vascular disease, has faced a steep adaptation-curve.169  

The VA’s challenge is multi-faceted.  War zone injuries that result in amputations are often complex and can prove difficult for later prosthetic fitting because of length, scarring, and additional related injuries, such as burns.170  The VA has instituted an amputation system of care and initiated the development of amputee centers of excellence which can become important components of needed changes, but WWP’s experience is that much more progress is needed to realize the underlying vision.  DoD has surpassed the VA in providing state of the art rehabilitation for this generation of combat-injured amputee service members and veterans.171  Some have suggested that VA’s leadership role in prosthetics has declined and that prosthetics no longer holds the priority for VA it did in the past.172  The VA’s prosthetics research, particularly – an area of real strength in the past and so important to serving wounded warriors tomorrow – has lagged, even as the numbers of new veteran-amputees climb steadily.173

With OEF/OIF veterans being seen at VA medical facilities across the country, any one particular medical center may provide prosthetics care to only a few young veterans.  The average age of an OEF/OIF warrior at the time of injury leading to an amputation is 25.174  Their active lifestyle frequently requires specialized equipment with which VA staff at some facilities – unable to keep uniform pace with technological advances – often lacks familiarity.175  Today, some 39% of the OEF/OIF amputee population returns to DoD to receive prosthetic care.176 While DoD is currently able to shoulder that demand, WWP is concerned that, as the current conflicts draw down, DoD facilities will ultimately scale back their services and associated funding with the decline in combat injuries.  The VA must be ready to meet this need; but it is not yet there.  There are pockets of excellence within the VA’s prosthetic system, but that level of expertise is not consistently available to veterans across the VA system.

Wounded warriors advise WWP that the paradigm shift in amputee care has yet to become evident at most VA medical centers.   In fact, an amputee being seen at a primary care clinic is seldom, if ever, asked how the individual’s prosthetic is working, and whether it is causing pain.  Prostheses should be prescribed on the basis of careful evaluation, and joint patient-clinician decision-making that takes account of best medical evidence and practice.177  But, as warriors attest, VA clinicians themselves often base decisions about orthotic and prosthetic equipment on past practice and word of mouth, rather than informed medical judgment, with the result that the choice of equipment may or may not be appropriate.178  With wide variability in providers’ knowledge and expertise with new prosthetic technologies, warriors report significant disparities from facility to facility in the approval of specific durable medical equipment.179

Congress has long seen the VA’s prosthetics program as critical to meeting the specialized rehabilitative needs of disabled veterans.  But substantial changes in VA’s prosthetics program – particularly, a controversial change in VA’s procurement of prosthetics items180 --  have sparked concerns regarding VA’s capacity to provide wounded warriors needed prosthetic and orthotic equipment in a timely, effective manner.

Given how critical prosthetics care and prescribing practices are to warriors’ rehabilitation and empowerment, WWP calls on the VA and Congress to take steps to improve that care.  WWP has long urged the need to improve system-wide coordination and consistency, and recommends steps toward continued improvement of the prosthetics program, to include the following:

  • Ensure through ongoing oversight that the vision of a VA Amputee System of Care is realized; that the VA meets its commitment to provide timely, needed prosthetics; and that it works to regain leadership in prosthetics research and service;  
  • Ensure that the VA’s amputee-registry is deployed and used to track amputee-care and outcomes, conduct longitudinal studies and other research, and – working in concert with DoD -- expand understanding of best practices;
  • Establish a steering committee of experts composed of academicians, clinicians, and researchers to oversee and provide guidance to the VA on the direction and operation of its prosthetics and orthotics program;
  • Develop clinical practice guidelines to assist clinicians in more appropriately prescribing durable medical equipment;
  • Serve warriors more effectively through such VA measures as: (1) creating an equipment-loan center or centers through which warriors could borrow and test equipment before final issuance; (2) providing veterans -- in addition to any primary assistive device needed for mobility or to perform ADL’s -- with functional spare equipment; and (3) expanding efforts to develop informative materials for veterans and caregivers on available devices; and
  • Assign additional VA prosthetics and sensory aids staff at military amputee centers of excellence.

Congressional oversight to ensure both preservation of the prosthetics’ system strengths and the VA’s progress in improving the quality of its prosthetics and orthotics care together with the VA’s adoption of the above recommendations would go a great distance toward improving the lives of those who have lost limbs in our ongoing war, and improving the care of veteran-amputees of all generations.


Please download the 2013 Policy Agenda and refer to pages 24-25 to access references for this section.

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