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Vocational Rehabilitation of the Combat Amputee

Chapter 6

VOCATIONAL REHABILITATION OF 

THE COMBAT AMPUTEE

MICHAEL PRAMUKA, PhD*; JAMES M. MacAULAY†; MICHELLE L. SPORNER, MS, CRC‡; and MICHAEL McCUE, PhD§

INTRODUCTION

BACKGROUND 

Legislation

Vocational Rehabilitation Professionals

Outcomes

Vocational Rehabilitation and the Combat Amputee

THE VOCATIONAL REHABILITATION PROCESS

Assessment and Career Exploration

Development of the Rehabilitation Plan

Intervention and Training

Follow-Up Services

SUPPORTS AND SYSTEMS FOR VOCATIONAL REHABILITATION OF THE COMBAT VETERAN

Psychosocial Adaptation to Amputation

The Veterans Affairs Vocational Rehabilitation System

The Public Vocational Rehabilitation System

A MODEL SYSTEM FOR VETERANS WITH DISABILITIES

SUMMARY

*Assistant Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, 5044 Forbes Tower-Atwood, Pittsburgh, Pennsylvania 15260; formerly, Neuropsychologist, Henry M. Jackson Foundation/San Diego Naval Medical Center, 34800 Bob Wilson Drive, San Diego, 

California

†Chief of Vocational Rehabilitation, Department of Physical Medicine and Rehabilitation Services, James A. Haley Veterans’ Hospital, 13000 Bruce B. 

Downs Boulevard, Tampa, Florida 33612; formerly, Vocational Rehabilitation Specialist, James A. Haley Veterans’ Hospital, 13000 Bruce B. Downs 

Boulevard, Tampa, Florida

‡Research Assistant, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System/University of Pittsburgh, 7180 Highland Drive, 

Building 4, 2nd Floor, 151R1-H, Pittsburgh, Pennsyvlania 15206

§

Associate Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, 5050 Forbes Tower, Pittsburgh, Pennsylvania 

15260
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Care of the Combat Amputee

INTRODUCTION

a job or retraining for competitive employment in the 

civilian sector.

This chapter summarizes the basic components of 

VR of the combat amputee, describing both the general 

process of preparing an individual with amputation 

to return to work and the issues related to vocational 

success specific to combat amputees. The structure 

and opportunities of Department of Veterans Affairs 

(VA) vocational rehabilitation are outlined. The chapter 

concludes with a description of a model system developed over several years via collaboration between the 

vocational rehabilitation service of the James A Haley 

VA Hospital and the Veterans Benefits Administration (VBA) staff at the St Petersburg, Florida, regional 

office.

Vocational rehabilitation (VR) refers both to the 

overarching goal of returning an individual to gainful employment after he or she acquires a disability, 

and to a complex process of assessment, counseling, 

support services, and retraining that should begin, at 

least conceptually, shortly after the onset of disability. 

Cultural values of independence, self-sufficiency, and 

the importance of being able to contribute to the community provide a strong incentive for individuals to 

return to employment, and both local and national 

communities recognize the financial and humanitarian 

value of maximizing employment. In today’s rapidly 

changing world, service members with amputation 

are more likely than ever to remain on active duty 

status in the same or a modified position, or to seek 

BACKGROUND 

Legislation 

In the United States, systems of VR have been 

initiated primarily in response to wartime casualties, 

then mandated and broadened for civilian populations afterwards via federal legislation. The Soldiers 

Rehabilitation Act was passed in Congress in 1918 

to require vocational education for returning World 

War I soldiers with disabilities. Additional legislation broadened the scope of VR services to individuals with blindness, mental retardation, and mental 

illness. World War II resulted in the 1943 Disabled 

Veterans Act, which authorized vocational support, 

and the 1944 Servicemen’s Readjustment Act, which 

provided vocational training and education for those 

whose careers were cut short by military service. The 

1952 Veterans Readjustment Assistance Act provided 

vocational education to Korean War veterans. Additionally, the shortage of traditional employees in 

World War II created an opportunity for individuals 

with disabilities to demonstrate their ability to participate competitively in the workforce, resulting in 

additional legislation broadening VR and education 

for civilians. The 1973 Rehabilitation Act resulted in 

significant infrastructure growth for VR; 25 years later 

the 1998 WorkForce Investment Act brought dramatic 

changes to the field. 

Vocational Rehabilitation Professionals

VR services, particularly in terms of initiating 

support and developing employment plans, have 

primarily been provided in both the VA and the public 

sector by the discipline of rehabilitation counseling. 

The field of rehabilitation counseling was developed 

as master’s level education of professional counselors 

with specialty training in disability, medical aspects of 

disability, advocacy, career guidance and vocational 

assessment, and rehabilitation systems. Rehabilitation 

counselors have a national credential, the Certified 

Rehabilitation Counselor (CRC), and in many states 

are licensed as master’s level counselors. Rehabilitation counseling is defined by recognized competencies 

expected of a CRC; some of these identified in the CRC 

Scope of Practice include career counseling, assessment 

and appraisal, case management, referral and service 

coordination, job analysis, job development, placement 

services including assistance with employment and job 

accommodations, and interventions to remove environmental, employment, and attitudinal barriers.1

The national credentialing body for master’s programs in rehabilitation counseling, the Council on 

Rehabilitation Education, also specifies competencies 

for all graduates of rehabilitation counseling programs. 

A brief review of these competencies confirms that 

training and expertise in VR are essential aspects of 

rehabilitation counseling. Competencies include the 

following: 

	 •	 utilize career and occupational materials and

labor market information with the consumer 

to accomplish vocational planning; 

	 •	 evaluate work activities through the use of job

and task analyses and utilize the evaluation 

in facilitation of successful job placement; 

	 •	 establish follow-up procedures to maximize

an individual’s independent function through 

the provision of postemployment services; 
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Vocational Rehabilitation of the Combat Amputee

	 •	 use computerized systems for consumer job

placement assistance; and

	 •	 identify and arrange educational and training

resources that can be utilized by consumers 

to meet job requirements.

Other rehabilitation professions may also be 

involved with VR in some settings, particularly occupational therapy, psychology, or social work. Some 

aspects of the rehabilitation counseling profession may 

overlap with psychology and social work, particularly 

in the areas of individual or group counseling services, 

discharge planning, case management, and treatment 

team coordination. Occupational therapists, in particular, often participate in evaluation of return-to-work 

status through a work hardening trial or a functional 

capacities evaluation that operationalizes fitness and 

safety for specific occupational tasks. 

Rehabilitation engineers often play essential roles in 

VR, identifying assistive technologies and providing 

training on how best to implement the technologies 

as an accommodation for either training or on the 

worksite. Rehabilitation engineers may also be involved with making worksite modifications, making 

recommendations for ease of computer accessibility, or 

prescribing and setting up an environmental control 

unit that allows the employee to remotely control numerous appliances or other electronic devices. 

Outcomes 

The professional literature describes vocational 

and psychosocial outcomes in individuals with amputation, although the heterogeneity of amputation 

and differences between the civilian population and 

the combat amputee render most findings unlikely 

to generalize to this group of individuals. Vocational 

rehabilitation has played an essential role in the rehabilitation and community reentry of other disability 

groups. 

Vocational Rehabilitation and the Combat Amputee 

VR is tailored to the characteristics of each individual who has experienced a disability. Given their 

active duty status before injury, combat amputees tend 

to be young, fit, healthy, and oriented to physical activity, competition, and independence. These individuals, 

at least since the end of the draft in 1973, have chosen 

a career path in the military knowing of its increased 

level of risk, as well as uncertainty about living conditions, job duties, and an ongoing need to reestablish 

new peer relationships. These preinjury characteristics 

imply a set of values and expectations for employment 

and independent living that may differ significantly 

from other groups of amputees, such as sedentary, 

elderly persons with chronic medical conditions, who 

make up the largest group of amputees. In general, the 

characteristics of combat amputees imply significant 

motivation to return to employment and strength of 

character to tolerate the ambiguity of VR. However, 

these same characteristics may present some obstacles 

to VR. Many service members have had a hiatus from 

their academic discipline and may find it difficult 

to reengage in academics, reducing their interest or 

confidence in their ability to succeed in vocational 

retraining programs. 

A unique characteristic of military service members 

is a shift in primary identity from an “I” to a “we” 

upon joining the military, placing service to the country 

and protection of fellow service members over their 

individual needs. This value greatly facilitates success 

in combat, but may be inconsistent with planning for 

individual goals; the combat amputee may need to reprioritize the self and personal needs over group needs 

to successfully engage in the VR plan. Many veterans 

maintain this core value for their entire lives.

An additional component of VR is to plan pragmatically for employment. In today’s military population, 

some service members may have learned English as a 

second language, and may not have been formally educated in English. Concurrently, some service members 

may have joined the US armed forces from another 

country in the hopes of facilitating US citizenship for 

themselves, and are not currently US citizens. Both 

of these issues need to be considered in light of the 

demands of academically oriented vocational training 

programs, the requirements for employment, and the 

long-term opportunities for employment if the service 

member chooses to return to the home country to be 

closer to family and friends.

A third tenet of VR is evaluation of the individual’s 

strengths and limitations, taken as a whole, after injury 

has stabilized. For combat amputees, the mechanism 

and context of amputation is therefore a significant 

factor for future VR. The current etiology of limb loss 

due to explosions and motor vehicle accidents often 

includes numerous additional injuries such as spinal 

cord injury, burns, orthopedic injuries, and head 

trauma (and resultant cognitive or other dysfunction). 

These additional injuries greatly challenge the VR 

process and may supersede amputation as the primary limitation or consideration in identifying future 

employment opportunities. However, the context of 

combat limb loss in the system of care provided by the 

Department of Defense (DoD) acutely and postacutely 

differs significantly from typical civilian amputee care. 

In the DoD, active duty personnel are very likely to be 
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Care of the Combat Amputee

recuperating in the company of other service members 

with similar injuries, providing a built-in support 

network and an organizational structure oriented 

to optimal rehabilitation and access to cutting-edge 

prosthetics. 

A fourth basic issue to consider in VR is the feasibility of transferring past work experience to future 

employment options. The employment circumstances 

of active duty personnel differ dramatically from civilians both in overall format and frequently in specific 

job duties. Although many of the tasks completed by 

service members have a parallel in civilian settings, 

other duties are much more specific to military needs 

and have no clear parallel position in civilian employment. However, some resources are available to assist 

in generalizing from military to civilian employment, 

which will be discussed in the next section. 

In addition, many individuals with a combat amputation are young and may have joined the military 

due to a lack of other vocational direction; often they 

have not had other types of work experience. This 

group may require more evaluation and exploration 

to determine a future employment direction. Although 

the opportunity to remain on active duty has greatly 

increased and a formal return-to-duty process exists, 

some service members may be unwilling to pursue 

this route if they are unable to return to their previous 

military occupational specialty. 

Finally, the VR process must include consideration 

of long-term needs and outcomes in determining type, 

location, and characteristics of employment. As previously stated, the literature on long-term outcomes for 

individuals with combat amputations has been scarce; 

however, individuals with amputations resulting from 

the current conflicts represent a unique population in 

which the complexity of injury mechanism along with 

polytrauma, access to rapid medical and rehabilitation 

services, and access to state-of-the-art prosthetics all 

combine to produce an individual with significantly 

greater opportunities for functional recovery than 

previously seen.

The vast majority of service members with amputations are rated by the VA system as having some level 

of disability, or percent of “service connection” for the 

amputation. This commits the VA healthcare system to 

lifelong medical and rehabilitative care for the service 

member for any needs related to the disability. Therefore, many service members with limb loss find proximity to a VA hospital or a military medical treatment 

facility (MTF) that offers these services, in addition 

to the ongoing needs for rehabilitation, therapy, and 

modifications with a VA prosthetics service, to be an 

important factor in choosing a location for long-term 

employment. For individuals considering retraining 

in new career fields, additional consideration will 

therefore need to be given to the “transferability” of 

employment from a current home to areas with access 

to VA rehabilitation services. 

THE VOCATIONAL REHABILITATION PROCESS

This section summarizes various VA and DoD systems and potential paths to access VR services. For 

the service member with amputation as the primary 

injury, medical and rehabilitation services are most 

likely to be provided in an MTF with specialized amputee care resources. Military MTFs now have access 

to VR professionals, who may establish preliminary 

rapport with service members and determine when 

to make formal referral to initiate the VR process. 

Particularly for those service members who express 

interest and are likely to remain on active duty status, consultation with VR specialists occurs after 

stabilization and transfer to outpatient rehabilitation, 

when functional status is better known and return to 

employment ability can be assessed and discussed in 

a realistic manner. 

The VA incorporates VR specialists in some hospital 

settings and in VBA offices. For service members sustaining polytrauma, transfer to a VA polytrauma center 

may occur early in rehabilitation. These individuals are 

treated by a transdisciplinary team that includes VR. 

The VR team member can begin to provide education 

to family members and to the service member about 

VR options. Depending on severity of disability, some 

of these individuals may become veterans and may in 

fact need access to VA VR benefits to assist in transition 

to community-based services upon discharge from 

the military.

For medical professionals working with a combat 

amputee, a brief overview of the basic components of 

VR is offered here. VR begins early in the rehabilitative process and must be understood, reinforced, and 

supported by all professionals providing services 

to the combat amputee. VR steps discussed below 

include assessment and career exploration, rehabilitation plan development, intervention and training, 

and ongoing follow-up.

Assessment and Career Exploration

VR involves a process of intake and referral to services within DoD, VA, and community settings that 

will ultimately support future efforts toward return 

to employment, as well as a process of individually 
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Vocational Rehabilitation of the Combat Amputee

oriented assessment and intervention. Both intake 

and preliminary assessment can begin early in the 

rehabilitation of the combat amputee, but these initial 

steps must lead to a rehabilitation plan developed in 

conjunction with the individual service member. It is 

critical to include an overall assessment of strengths 

that might contribute to future employment, not just an 

evaluation of ambulation or other motor and sensory 

skills presumed to have changed after amputation. 

Assessment should be conducted after the service 

member has had ample time to adapt to prostheses or 

any other compensatory strategies.

Individually oriented assessment uses a variety 

of interviews, observations, standardized questionnaires and tests, and techniques, not all of which 

are necessary or relevant for every individual. In 

general, the process follows this sequence: interview 

and background gathering, evaluation of transferability of previous employment, tests or other data 

gathered on current ability level, determination of 

current interests, functional or situational assessment 

to assist the individual in exploring fit to a position, 

matching of current personal attributes to potential 

jobs, and finally a market study to determine utility 

of career choices.

Assessment in VR includes current abilities and aptitudes, interests and preferences in type of work, and 

transferability of skills from previous employment or 

training to other jobs. Abilities and aptitudes may be 

identified via formal testing of intellectual, academic, 

motor, and sensory abilities; through informal interviews; and by observation in real world environments 

as the individual attempts various tasks. Numerous 

interest inventories, such as the Self-Directed Search, 

are available as written exercises.2 Data on interests 

is gained in interviews with veterans about hobbies, 

avocational interests, and past successes, as well as 

interviews focused on why they have chosen previous 

employment and their subsequent subjective experiences with the work environment and work tasks. In 

determining transferable job skills, it may be useful 

to acquire a formal job description of the military 

occupational specialty as well as to conduct detailed 

interviews about daily function.

Numerous Internet-based programs are available 

to assist with career guidance, particularly to gain 

detailed information about the demands of specific 

jobs, educational requirements, and job prospects. 

These programs are often best used initially under 

the guidance of a VR counselor, but lend themselves 

well to further independent exploration by veterans. 

The most comprehensive Internet resource is ONET, 

available at www.onetcenter.org (previously available 

in hardcopy as the Dictionary of Occupational Titles3). 

Several online resources can assist in comparing 

military occupational specialty with civilian sector 

employment, including a “crosswalk” page on ONET 

and Transition Assistance Online (at www.TAOnline.

com). In addition, the American Council on Education offers a Web site that describes military training 

programs and compares them to educational training, assigning college credits to past military training 

(www.militaryguides.acenet/edu). 

Development of the Rehabilitation Plan

Depending on residual abilities, interests, and the 

demands of employment, there are typically four 

possible directions for VR, in the following order of 

preference: (1) return to previous employment in active 

duty status; (2) remain in the military, but in another 

military occupational specialty; (3) leave the military 

and seek civilian employment using current skills; or 

(4) leave the military and seek retraining for new skills 

or a new environment. Each combat amputee may 

have specific opinions and preferences about which of 

these directions to pursue, but will also need to abide 

by military decisions and policy regarding retention 

of active duty personnel with limb loss. 

As an individual moves closer to a specific vocational choice, an assessment of the impact of disability 

characteristics as he or she interacts with the environment is critical. This process of functional assessment 

can take many forms, but ultimately must address 

the day-to-day realities of employment and identify 

compensatory strategies and accommodations that the 

amputee may use to meet the demands of competitive 

employment.

Baseline Function

As an initial step in the rehabilitation plan, the service member must reestablish and achieve a baseline 

level of independent function that is robust enough to 

remain secure in the face of the demands of return to 

work or participation in retraining. For many service 

members, particularly those with comorbid conditions, this will entail the development and description 

of a “prevocational” phase of therapy and supports 

tailored to their specific needs. Areas to evaluate and 

support include basic activities of daily living, such as 

personal hygiene, dressing, and self-feeding; home and 

nutritional management; finances; ability to negotiate 

medical and rehabilitation appointments; and medication management. 

A particular point of concern is the ability to 

maintain attention and endurance equivalent to a 

work-oriented daily schedule, and then return home 
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Care of the Combat Amputee

to attend to other requirements of independent adult 

life. Emotional status is also a critical component of 

baseline coping—the demands on emotions escalate 

with increased responsibilities—and the attainment 

of adequate coping strategies may require ongoing 

counseling services, support groups, family education, or other supports. To address these issues, the VR 

plan often details a list of prevocational therapeutic 

activities involving ongoing outpatient medical rehabilitation, professional counseling, or participation in 

community-based reentry programs. These services 

are typically funded under VA independent living 

services.

Functional Assessment

A second aspect of developing a VR plan is functional assessment, to determine the veteran’s current 

abilities in the everyday world.4 This assessment may 

include functional capacity evaluations by occupational or physical therapists to identify specific levels 

of physical ability as related to work demands, work 

hardening programs that require individuals to return 

gradually to the demands of employment, functional 

interviews, and situational assessments (discussed 

below).

Interviewing individuals and collateral informants 

is another way of obtaining information about functional abilities and competencies in the everyday environment. Spouses, housemates, employers, coworkers, 

caregivers, and adult children can provide rich information on an individual’s ability to perform a certain 

task, how an individual goes about performing a task, 

how the individual’s environment is structured, what 

obstacles he or she encounters, and the supports the 

individual needs and has access to. 

A functional interview is an extension of the information-gathering process that starts with collecting 

background information. The functional interview 

differs from the traditional clinical interview in its 

emphasis on the individual’s current environment 

and relationships between that environment and 

current problems. It also differs in its emphasis on 

exploring the interface between cognitive strengths 

and limitations and everyday life. Its purpose is not 

to provide a historical view of social, vocational, 

educational, medical, or familial background; to 

conduct an interview that elicits truly functional 

information, it is critical to keep these two agendas 

separate. The goal of a functional interview is to 

provide specific information on what individuals can 

or cannot do. Examples of what might be obtained 

include a specific picture of daily life schedule and activities; statements detailing the impact of problems 

on everyday life experiences; or a list of previously 

attempted remedies.

The manner of questioning is important because it 

may influence the response. For example, asking an 

informant whether an individual “can” perform a task 

may produce a different (and perhaps less accurate) 

response than asking if the person regularly “does” a 

task. Asking about how an individual goes about a task 

(the approach, strategies, and accommodations used) 

can provide the rehabilitation counselor with information to make generalizations about other functional 

skills and future behaviors. Systematic collection of 

information from both veterans and informants using 

rating scales or questionnaires may shed light on the 

problems that may not be apparent from test results. 

There are often dramatic differences in how individuals rate themselves versus how family or caretakers 

rate executive function.

Simulations and role-playing of real-life activities 

can be used to determine how an individual utilizes 

interpersonal and cognitive skills to resolve problems.5

These activities require the individual to deal with 

multiple priorities, unforeseen circumstances, and 

interpersonal interactions—the real tests of effective 

executive function. Situational assessments are completed by putting the individual in a real-life environment and observing how he or she functions over a 

period of time. These short-term real-life experiences 

can be arranged through temporary employment, often through the use of a temporary personnel agency. 

Volunteer work or short-term employment arranged 

through family or friends can also be considered. Large 

institutional settings such as a VA hospital or MTF 

offer a protected setting to establish a wide variety of 

short-term employment-oriented simulations, given 

the wide range of professions and environmental 

demands in such places and the relative facility an 

inside employee may have in developing such a 

simulation.

Situational assessments can be arranged to match 

the demands of training environments if the individual’s vocational goals include training. Arrangements 

can be made for individuals to sit in on classes on a 

time-limited basis, or they can attend professional 

seminars or continuing education courses to assess 

their response to training at this level. In any context, 

a situational assessment permits evaluation of executive function across time and in the face of real-life 

demands and conflicts that closely parallel the employment or educational settings in which the person will 

need to function.

Cognitive endurance, ability to adjust to new demands and learn from the environment, social interactions with coworkers and supervisors, and problem-
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Vocational Rehabilitation of the Combat Amputee

solving with transportation can all be observed during 

a situational assessment, even in a field unrelated to 

the individual’s expressed vocational goal. The individual’s ability to perform in his or her own environment may be markedly different than performance in 

other settings would predict, and should be assessed 

through direct observation. Observations can be completed at the individual’s job site, in the classroom, 

or in his or her home, depending on the individual’s 

level of functioning

Individual Choice

A third aspect of career guidance and exploration 

is the issue of consumer choice, or empowerment, 

especially in relation to vocational goals and choices 

about future employment and training. An individual 

may not spontaneously propose a vocational path that 

a professional deems most feasible, or may decline 

to participate in formal VR efforts when initially approached. It may be tempting to impose vocational 

goals on an individual that from an outside perspective appear to be a good fit. Ultimately however, each 

individual will need to maintain the motivation and 

commitment to the training and employment outlined, 

and will not be able to do so unless the choice was 

made freely. These issues have been detailed in a 2005 

Institute on Rehabilitation Issues paper.6

Intervention and Training

In general, opportunities for intervention in VR fall 

broadly into three categories: (1) enhance the person’s 

abilities; (2) change or modify the environmental demands; or (3) both. In terms of ability, VR may provide 

funding for a training or educational program to prepare the veteran for a new career. VR may also provide 

counseling or learning supports to assist veterans 

with the challenges of the new learning environment, 

particularly if the disability has a cognitive or emotional component. VR may also make environmental 

modifications, such as purchasing modified work 

stations, assistive technology, or other strategies in an 

environment that facilitates employment. 

VR uses numerous strategies to support veterans 

as they return to employment. Among these are assistance in finding employment (job development), 

on-the-job coaching that diminishes over time as 

the veteran becomes more capable (job coaching), 

temporary employment positions that provide an 

opportunity to improve work skills (transitional 

employment settings), and on-the-job development 

of compensatory strategies and accommodations that 

allow the veteran to work competitively. The concept 

of supported employment using some version of a 

job coach has been a part of VR for individuals with 

significant disabilities since the 1980s.7,8 Concurrent 

with outpatient rehabilitation, institutional settings 

such as warrior transition units (or medical holding 

companies) offer an opportunity to initiate return 

to work in a supported, safe environment without 

demands on the client to meet the level required of 

competitive employment.

The current use of structured and supervised employment with professional support in VA hospital 

settings, or compensated work therapy (CWT), is 

one version of a supported employment program. 

CWT is a recovery-oriented model of VR to assist 

veterans with disabilities in gaining prevocational and 

vocational skills through employment opportunities 

throughout the VA and with local businesses based 

upon the individual’s goals. CWT offers supported 

employment services while providing vocational assistance and counseling for a predetermined amount 

of time. Veterans work a specified number of hours 

each week as part of the therapeutic process to develop 

appropriate work habits and to facilitate the transition 

into full-time employment. Some CWT programs also 

have a CWT/transitional residence program to offer 

additional support with housing while the veteran is 

using CWT services.9 Service members with complex 

acquired disability, however, may need professional 

support on the job over an extended period of time, 

and the psychosocial model of CWT may not be able 

to provide the full complement of vocational supports 

necessary.

Follow-Up Services

The “endpoint” for successful VR is controversial. 

Each program involved in VR is likely to have defined 

for itself a measure of successful outcome, but in the 

interests of serving the combat amputee, successful 

rehabilitation should better be conceptualized as a 

path rather than an endpoint. Work environments are 

dynamic, with ongoing and unpredictable changes 

in supervisory practices, coworker relationships, and 

intensity of workload; concurrently, physical status 

and stamina after amputation may also change over 

the years due to chronic pain, prosthesis comfort and 

tolerance, or prosthesis functionality. It is critical that 

any time a service member is referred for some aspect 

of VR, follow-up contact is maintained to ensure that 

the requested services are provided and that they result in the intended consequence. Frequently, multiple 

barriers arise unexpectedly, and medical professionals 

working with a combat amputee may need to reassess 

or redefine the VR plan.
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Care of the Combat Amputee

SUPPORTS AND SYSTEMS FOR VOCATIONAL REHABILITATION OF THE COMBAT VETERAN

ultimately will facilitate return to independence and 

employment. General themes that may appear in any 

contact with service members include distress over 

appearance, a shift in personal values and goals, and 

identifying personally relevant goals to maintain motivation and stamina throughout the long rehabilitation 

process. Professionals may also be able to support service members as they begin to compare strengths and 

limitations of their “new self” in comparison to their 

“old self,” offering a sounding board as amputees rehearse new ways to explain their current circumstances 

and changes to others. Veterans are also faced with the 

need to rapidly absorb complex medical information, 

synthesize it with family needs and personal values, 

and make weighty decisions about return to active 

duty, surgical and other treatment options, and use 

of prosthetics. These topics are all best addressed in a 

supportive, nonconfrontational manner, with repeated 

discussion until the veteran has become comfortable 

with a decision. 

The Veterans Affairs Vocational Rehabilitation 

System

The VBA and DoD now operate a complex and 

detailed system of benefits that support VR for service 

members with a service-connected disability. An overview is provided here along with a description of VR 

services that may also be found in some VA healthcare 

facilities. An excellent summary is also offered at www.

vetsuccess.gov. It is critical to note that funding and 

overall direction of VR occurs not within the hospital 

system but in the veterans’ benefits system.

The primary vehicle in the VA system to implement 

rehabilitation plans is in the VBA Office of Vocational 

Rehabilitation and Education (VR&E). The VR&E employs rehabilitation counselors, housed under the VBA 

in regional offices, to develop and implement rehabilitation plans for veterans with disabilities. Typically, 

veterans with at least a 20%-level of service-connected 

disability are eligible to apply for VR under Chapter 

31 of Title 38 of the US Code. For many veterans with 

significant disabilities, however, prevocational programs including ongoing therapy and community 

reintegration are required as the initial step in the VR 

process. The VA system may provide these services 

under an independent living program. 

VR&E rehabilitation counselors assist veterans in 

applying to the program using Form 1900. Once the 

veteran is found eligible, VR&E may provide services 

under a rehabilitation plan for extended evaluation, 

independent living, or education and training. The VA 

Psychosocial Adaptation to Amputation

Early in the rehabilitation of the combat amputee, 

it is critical to facilitate psychosocial adaptation to 

disability. It is much less important who intervenes 

to accomplish this, and much more relevant that all 

medical professionals providing services to the combat 

amputee have a basic orientation to possible psychological responses and changes after amputation.

It is important to communicate to the combat amputee that rehabilitation is a learning process, requiring 

rehearsal of new skills and a willingness to try new 

ways to accomplish old tasks. Neither acute rehabilitation nor eventual return to employment comes without 

attention, effort, and motivation to acquire new strategies, sequences of movement, and new attitudes and 

values. At times, the VR process may seem distant or 

unclear, and in fact it requires tolerating a high degree 

of ambiguity. This rehabilitative process involves ongoing change and modifications to the individual’s 

overall level of function. Consequently, amputees 

cannot rapidly make an internal determination about 

their ultimate level of function. 

One goal of rehabilitation professionals is to facilitate coping with amputation. Livneh et al10 examined 

coping responses in a group of 61 amputees, noting 

that coping styles of amputees are similar to other 

groups of people dealing with a variety of illness or 

other life stressors. Generally, individuals chose between active coping/problem-solving perspectives 

versus denial, optimism versus pessimism, and seeking external support (talking to others, asking advice) 

versus internally oriented acceptance.

A wide variety of personal factors may be involved 

in psychosocial changes after amputation. Shifts in 

body image and personal identity, phantom pain or 

residual limb pain, and emotional changes related 

to depression or anxiety have all been noted in other 

amputee populations as potential areas complicating 

recovery. Horgan and MacLachlan11 reviewed a wide 

range of published studies on psychosocial outcomes 

after amputation, concluding that better adjustment 

was associated with active coping, optimism, good 

social support, increased time since amputation, and 

less pain. These characteristics make intuitive sense, 

but are often lost in considering a specific individual 

and where professional intervention may fit at the 

current stage of the rehabilitation process.

Service members with amputations will encounter 

a wide range of professionals as they traverse their rehabilitation paths, most of whom have an opportunity 

to provide some aspect of psychosocial support that 
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Vocational Rehabilitation of the Combat Amputee

process includes significant opportunities to ensure 

that veterans with a disability are fully prepared before 

initiating a formal education/training process. 

Services for VR within VA hospitals currently 

vary widely from facility to facility. Those with the 

greatest emphasis on rehabilitation, particularly the 

polytrauma centers, are best equipped to provide 

face-to-face direct VR evaluation and career guidance. 

Increasingly, VA hospitals also have implemented the 

CWT program. 

The Public Vocational Rehabilitation System

Each state is required by the federal government to 

establish and maintain a public VR system for citizens 

with disabilities. Established in 1920, the funding 

stream for public VR is now a mix of federal and state 

monies. Eligibility for VR services is based on documentation of disability and the decision that the disability represents a significant obstacle to competitive 

employment. The public VR system can provide a wide 

variety of resources and supports for an individual, 

including counseling, assessment, job development, 

and job coaching, as well as financial support for tuition and other fees associated with vocational training 

programs. The public VR system defines itself as the 

“payor of last resort,” meaning that services should 

always be funded first by any other resource. Hence, 

the veteran who incurred an amputation in combat 

may more likely receive VR services under the VA, 

but may still be eligible for some public benefits, such 

as reimbursement of transportation. 

A MODEL SYSTEM FOR VETERANS WITH DISABILITIES

VR services for veterans under Chapter 31 involve 

an exchange of information and collaboration between 

the VBA VR&E counselor and a contractor. A model 

program to facilitate rapid entry into the VBA VR 

system and timely deployment of a rehabilitation plan 

has been developed and disseminated by the joint efforts of the VR service of the Tampa, Florida, VA and 

the local regional benefits office in St Petersburg.12 An 

outline of this model is provided here.

The Tampa model requests consultation from all 

programs that serve veterans likely to qualify for or 

need VR services upon admission; this ensures that the 

veteran will be identified as a potential VR candidate 

early in the rehabilitation process. The model includes 

ongoing collaboration between a VA VR specialist, a 

VBA VR&E counselor, and the assigned contractor in 

the community brought in to facilitate the rehabilitation plan. This collaboration includes face-to-face meetings and participation, when feasible, in client staffing. 

The VA hospital staff facilitates any necessary medical 

appointments for evaluation, triaging the requests. VA 

staff initiate vocational evaluations with veterans when 

relevant and appropriate, and maintain ongoing crosstraining between the two entities. Notably, the VR&E 

staff are considered primary stakeholders in the VR 

process, sharing common outcome measures in client 

satisfaction and effectiveness measures. The regional 

office also maintains an out-stationed VR&E counselor 

at the hospital, greatly facilitating the partnership. 

For service members who participate in inpatient rehabilitation services in a VA setting, this approach is 

critical to timely and coordinated benefits and access 

to appropriate services as they transition home or to 

other services.

SUMMARY

This short overview of the VR process for the 

combat amputee has reflected the complex nature of 

returning to employment after limb loss. The process 

requires assessment and involvement of the service 

member as well as knowledge, access, and coordination across numerous systems of support and institutional bureaucracies. Even for those individuals who 

experience a rapid and successful return to competitive 

employment, education, training, and follow-up to 

anticipate and manage changes in the work environment successfully are critical to long-term retention 

of employment. Initiating discussions and referrals 

related to VR is one of numerous preliminary steps in 

the rehabilitation of the combat amputee.

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