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U.S. Department of Veterans Affairs Research Programs.

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OCTOBER 4, 2007

SERIAL No. 110-50

Printed for the use of the Committee on Veterans' Affairs




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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
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.



October 4, 2007

U.S. Department of Veterans Affairs Research Programs


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
    Prepared statement of Congressman Miller
Hon. Henry E. Brown, Jr.


U.S. Department of Defense, Department of the Army, Major David Rozelle, Administrative Officer, Military Advanced Training Center, Walter Reed Army Medical Center
    Prepared statement of Major Rozelle
U.S. Department of Veterans Affairs, Joel Kupersmith, M.D., Chief Research and Development Officer, Veterans Health Administration
    Prepared statement of Dr. Kupersmith

Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of Government Relations
    Prepared statement of Dr. Zampieri
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
    Prepared statement of Ms. Ilem
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
    Prepared statement of Dr. Feussner
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
    Prepared statement of Dr. Lema
Paralyzed Veterans of America, Carl Blake, National Legislative Director
    Prepared statement of Mr. Blake


National Association of Veterans' Research and Education Foundations, statement
Orthotic and Prosthetic Alliance, statement
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
Salazar, Hon. John T., a Representative in Congress from the State of Colorado, statement


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

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


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.


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 the June 21, 2003, Major David Rozelle was leading a convoy west of Baghdad when his vehicle struck a land mine which resulted in the loss of his right foot. 

After spending eight 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 statement of Chairman Michaud appears in the Appendix. ]


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 statement of Congressman Miller appears in the Appendix. ]

Mr. MICHAUD.  I thank the gentleman.

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.



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.

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 approximately $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 scientists 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 statement of Dr. Feussner appears in the Appendix. ]

Mr. MICHAUD.  Thank you very much.



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.  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, computer-aided 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 lead 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 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-the-art 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 statement of Major Rozelle appears in the Appendix. ]

Mr. MICHAUD.  Thank you very much, Major.



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.

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 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 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 statement of Dr. Lema appears in the Appendix. ]

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.

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 state-of-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-of-the-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.

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.

So people who have actually had chronic pain that is more long-standing 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 to 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?


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 (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.



Dr. 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 that 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 in 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 to be admitted to nursing homes is actually falls.

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 act, 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 amounts of funding that is dedicated towards 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 in 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 towards 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 statement of Dr. Zampieri appears in the Appendix. ]

Mr. MICHAUD.  Mr. 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.

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 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 statement of Mr. Blake appears in the Appendix. ]

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

Ms. 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, research 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 got a wide range of possible mental health conditions such as readjustment disorder, anxiety, depression, PTSD, an