“Our service members and our veterans with limb loss deserve to have the best care, rehabilitation, and treatment we can offer them,” said Dr. Tawnee Sparling, medical director for amputee care at the Uniformed Services University’s Department of Physical Medicine and Rehabilitation. “This CPG is a big step forward in the ongoing effort to provide top-of-the-line treatment.”

The LLA CPG, a collaboration between the Department of Veterans Affairs and Department of Defense with oversight through the Defense Health Agency’s Office of Evidence Based Practice, was released in January 2025, and “offers important evidence-based research and recommendations for care and treatment of patients,” said Andrea Crunkhorn, chief of clinical affairs for the DHA’s Extremity Trauma and Amputation Center of Excellence who holds a doctorate in physical therapy.

The DHA resources are based on data obtained by treating more than 1,700 deployment-related amputations since 2001. Those clinical resources are updated as the science advances across the DOD and VA.

The CPG spans the continuum of LLA treatment from planning for surgery, the surgery itself, and through lifelong care, Crunkhorn said.

She emphasized the vital need for LLA guidelines.

“Amputation is one of those areas of medicine where there is not a lot of specific training,” Crunkhorn explained. “There are no formal programs of study in amputation at the national level where you can get an advanced certificate. Even at the international level, there is not much clinical practice guidance on how to manage these patients. Many clinicians rely on the CPG as a guidebook.”

“Clinicians are hungry for guidance on how to best serve their patients and how to maximize their outcomes,” she continued. “This includes getting them back to work, back into the community, back to any activity they enjoyed before their amputation. This CPG is a path to building that comprehensive guidance.”

In addition, the CPG plays a key role in MHS readiness, noted Sparling.

“It’s mission critical to be able to take care of our wounded service members and be prepared for future injuries,” she said. “The DOD aims to maintain the highest level of clinical practice within this specific field.”

Crunkhorn added, “At the height of the wars [in Iraq and Afghanistan], we were seeing hundreds of people at a time with some level of limb loss—typically multiple limb loss, blast injuries, and limb trauma. We need to be prepared for these events with a clinical practice guidelines and training programs in place before we go to war. There is no time once we've gone to war."

Building on research, improving care

The CPG on the Rehabilitation of Individuals with Lower Limb Amputation was last updated in 2017. Since that release, the evidence base on LLA has expanded.

“There is a focused dedication to getting the most recent research and the greatest evidence-based clinical guidance out to clinicians, and keep that cycle going,” said Crunkhorn.

Sparling noted how much can change in a five-year period.

“New research has been developed, designed, and published,” she said. “Some information from five years ago can be quite out of date, so making sure we've reviewed all new evidence is really important.”

CPG updates include:

• Recommendations on surgical procedures not included in the last CPG: “These procedures have been developing over the last five to 10 years and now have more evidence behind them,” said Sparling.
• Behavioral health: “We honed in on behavioral health—when you speak to providers caring for this patient population, it's quite obvious to them behavioral health is an important rehabilitation factor,” explained Sparling. “Historically, there has not been a lot of evidence. However, we’ve seen a push over the last five years to get more evidence published on the topic which allowed us to include it in the CPG.”
• Pain management: “Pain is a fact of daily life for most folks with limb loss,” Crunkhorn noted. “Providers are trying to get away from a reliance on opioids and other kinds of pharmaceutical management for pain. We looked at recommendations for emerging technologies and treatments like neurostimulation, ablation effects, and other interventions. Those are all really important areas to continue to explore."
• Peer support: “Having a certified peer visitor, trained through a formal certification program, visit a recovering service member can be a really a powerful tool, but there's very little research supporting this training,” said Crunkhorn. “We found evidence for peer support groups, but not necessarily for that subgroup of peer visitors. We do know it's important though, and the questions we’re asking on the topic offer direction for further study and exploration.”

The CPG also includes recommendations for other areas, like dosing for rehabilitation, where further study is needed. The intent is to drive future research.

“When we can't find evidence to respond to a key question or provide clinical guidance, we make sure to capture that,” said Crunkhorn. “Having an area of need identified in the CPG is very powerful for a researcher submitting an application to the VA and DOD … it creates an appetite and a desire to push that research forward and keep asking important questions.”

Delivering for patients

Crunkhorn found the process of updating the LLA CPG an invaluable effort.

“This is the third CPG I've worked on—it is a lot of work, but this community needs and deserves the support,” she said. “I am full of pride for the work we’ve done.”

Sparling agreed, saying, “[The CPG] took some sweat and blood to get to the point where it is now … but even if it changes just one patient's care, it was worth all of the time and effort.”

There will be upcoming training on this topic. The training will be part of the Veterans Health Affairs Amputation System of Care Education Series with a specific session devoted to this CPG on May 20, 2025, from 1 p.m. to 2 p.m. EST via live webinar. Training registration will be open ahead of the training date.

In collaboration with the VHA, the DHA CPG team updates, develops, and monitors clinical practice guidelines utilizing evidence-based practice. This partnership, along with understanding and incorporating patient needs from both the military and veteran health care systems, leads to improved patient outcomes. More than 25 CPGs have been produced from this collaboration. To learn more, visit the CPG web page.