Clinical Rehabilitation 2009; 23: 1044–1050

A prospective study of positive adjustment to

lower limb amputation
Jennifer Unwin University of Liverpool, Liverpool, Lynn Kacperek Lancashire Teaching Hospitals NHS Foundation Trust and
Chris Clarke University of Hull, Hull, UK

Received 2nd March 2009; returned for revisions 18th April 2009; revised manuscript accepted 2nd May 2009.

Objective: To examine prospectively the influence of demographic, amputation and

psychosocial variables on positive psychological adjustment outcomes for lower
limb amputees.
Design: A quantitative questionnaire study with two time points: at the beginning
of rehabilitation and at six-month follow-up. Multiple regression analyses were
used to determine the contribution of demographic/amputation factors versus
psychosocial factors to adjustment outcomes.
Setting: A regional outpatient specialist mobility and rehabilitation centre in the UK.
Subjects: Participants were recruited as a consecutive sample of new referrals
with lower limb amputation.
Main measures: Age, gender, level and cause of amputation were recorded.
The following measures were used: Hope Scale, Multidimensional Scale of
Perceived Social Support (MSPSS), Trinity Amputation and Prosthetic
Experiences Scale (TAPES) pain subscale initially and the Positive and
Negative Affect Scale (PANAS) and full TAPES at six-month follow up.
The measures were administered by two specialist nurses.
Results: Ninety-nine patients provided data at both time points. Hope at the
beginning of rehabilitation was related to positive mood (P50.001) and hope and
social support were related to general adjustment (P50.01, P50.001) at follow-up.
Demographic and amputation factors were not related to psychological adjustment
outcomes in this study.
Conclusions: The findings demonstrate prospectively the importance of psychoso-
cial variables in the prediction of positive adjustment to lower limb amputation.

Introduction in terms of mobility,1 return to work,2 body image,3

The amputation of a lower limb is a physical, emo-
tional and social challenge for the patient, their
family and services aiming to assist them. Lower
limb amputees have been shown to be compromised
Address for correspondence: Jennifer Unwin, Division of
Clinical Psychology, Whelan Building, University of
Liverpool, Liverpool L69 3GB, UK.
e-mail: J.unwin@liverpool.ac.uk
ß The Author(s), 2009.
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
pain,4 quality of life5 and anxiety and depression.6,7
The focus of the current study is psychological
adjustment. A variety of factors have been studied
as potential predictors of adjustment outcome for
patients.6 Research has been mostly cross-sectional
and has yielded equivocal findings in relation to the
importance of demographic factors such as age,
gender, level and cause of amputation.6 However,
a recent UK study with a two- to three- year
follow-up post inpatient rehabilitation found no
10.1177/0269215509339001

association between age, gender or cause of ampu-
tation and anxiety or depression.7
Most notably, there has been an exclusive
emphasis on studying ‘negative’ psychological
adjustment outcomes, such as anxiety and depres-
sion7 in prospective studies. Hanley et al.4 con-
ducted a large prospective study of psychosocial
predictors of adjustment to lower limb amputation
in the USA with phantom limb pain and depressive
symptoms as outcome measures. Social support
emerged as associated with less pain and depression
in their study, where initial levels of phantom pain
were controlled for. They highlighted the impor-
tance of future studies examining the predictors
of positive psychological well-being following ampu-
tation because ‘positive and negative outcomes are
not mutually exclusive and are not merely opposite
sides of the same domain’ (p.891). There has been a
unidimensional conceptualization of psychological
adjustment not only in studies with amputees to
date but in illness research more generally.8
Research making clearer the characteristics of
those who achieve better psychological outcomes
will provide useful information for rehabilitation
services aiming to promote adjustment to lower
limb amputation. The current study therefore
focuses on the prediction of positive psychological
well-being following lower limb amputation.
Cross-sectional research has indicated that, in
addition to social support, active problem-sol-
ving,9 optimism and perceived control10 are asso-
ciated with less depression in lower limb amputees,
demonstrating the probable importance of cogni-
tive factors in the adjustment process. Snyder,11 a
researcher in the field of positive psychology, has
shown that ‘hope’ can account for adjustment to
adverse circumstances including acquired disabil-
ity such as spinal cord injury and blindness.
Snyder11 describes hope as a person’s stable
thoughts about their ability to find ways to reach
their goals and to find the motivation to pursue
those steps. While it is closely related to other cog-
nitive factors (active problem-solving, optimism,
perceived control and self-efficacy) Snyder and
colleagues have demonstrated that hope has dis-
criminant validity beyond these other known
correlates of adjustment.12 There is an increasing
emphasis on the importance of cognitive factors,
such as hope, in the generation of positive coping
processes and positive mood which are now
Adjustment to amputation 1045
understood to underpin the process of adjustment
to a range of adverse circumstances including ill-
ness and disability.13 Hope is measured using a
brief questionnaire and is potentially easily under-
stood by staff and patients alike. Thus, hope may
provide researchers and clinicians with a parsimo-
nious method for capturing the cognitive factors
associated with psychological adjustment to lower
limb amputation.
The current study addressed a number of the
issues briefly raised above in relation to psycho-
logical adjustment in lower limb amputees. The
research comprised a prospective study of both
demographic and psychosocial variables in a rep-
resentative sample of new lower limb amputees.
Adjustment was conceptualized as the presence
of positive mood and a subjective rating of general
adjustment to the amputation as opposed to an
absence of anxiety or depression. It was hypothe-
sized that initial phantom pain, age, gender, level
and cause of amputation would not be related to
positive mood and general adjustment at follow-
up but that social support and hope would be.
Methods
The research received approval from the local
research ethics committee, the hospital trust’s
research and development department and the
centre’s research committee.
Participants were recruited as a consecutive
sample of new referrals to an outpatient specialist
mobility and rehabilitation centre. All new lower
limb amputees over the age of 18 were sent infor-
mation sheets and invitations to take part in the
research with their first appointment letter.
Recruitment and follow-up took place over a
24-month period. Planned exclusions were for
patients with significant cognitive impairment
based on Hodkinson’s Mental Test14 or those
who could not read and write English, as the ques-
tionnaires were only available in this language.
Patients were also excluded if they were too
unwell to take part or needed further surgery.
Patients agreeing to take part gave written con-
sent to their specialist nurse at their first appoint-
ment. They were then given the questionnaires to
complete and the nurse answered any questions.
Patients were followed up after six months
1046 J Unwin et al.

during routine appointments or by telephone by
their specialist nurse. Two specialist nurses admi-
nistered all the questionnaires. The data were ana-
lysed by the first author. The mean time from first
assessment to follow-up was 6.8 months. A flow-
chart illustrating the recruitment process is shown
in Figure 1. Those declining to take part gave rea-
sons such as being short of time or too tired.
Power analysis indicated that 103 patients were
needed for a multiple regression analysis with
adequate power (0.8), given a medium effect size
(0.15), seven predictors and a significance value set
at 0.05. The final sample comprised 99 patients.
Time 1 predictor measures
Phantom pain intensity was assessed using the
pain subscale of the Trinity Amputation and
Prosthetic Experiences Scales (TAPES).15 This
scale was developed to assess quality of life with
lower limb amputees with regard to adjustment,
restrictions, satisfaction with the prosthesis and
pain. It has good face, construct and predictive
validity.15 Phantom pain intensity ratings are
given on a scale of mild to excruciating (1–5) for
the proceeding week. Phantom pain is described as
‘pain in the part of the limb which was
amputated’.
Self-reported levels of social support were
assessed using the Multidimensional Scale of
Perceived Social Support (MSPSS).16 This scale
was used in the one existing prospective study of
64 patients excluded (31%) 205 referrals to centre
9 < 18 years old
17 upper limb amputees
20 transfer inpatients
16 too ill
1 dysphasic
141(69% of referrals)
1 significant cognitive potential participants
impairment
21 declined (15% of
120 (85% of potential)
potential)
participants time 1
21 not followed up (17.5 %
of time 1 participants)
4 deceased 99 participants time 2
6 too ill (82.5% of time 1
3 declined participants) mean time
8 could not be contacted to follow-up 6.8 months
Figure 1 Flowchart of the recruitment process.
social support, adjustment and amputation in the
USA.4 The instrument has good internal and test–
retest reliability16 and is a brief 12-item inventory
with a 7-point rating scale from ‘very strongly dis-
agree’ to ‘very strongly agree’ with items covering
support from friends, family and significant others
(potential scores between 7 and 84). The mean
total scale score was used (total score divided by
12). Zimet et al.16 report a mean total scale score
of 5.8 for a sample of undergraduates.
Hope was assessed using the Hope Scale.12 This
scale has 12 items which are self-rated on an 8-point
scale from ‘definitely false’ to ‘definitely true’. Four
items relate to ‘agency’ (goal-directed determina-
tion) and four assess ‘pathways’ (planning ways
to meet goals) and four items are fillers (potential
scores between 8 and 64). Internal reliability and
test–retest reliability are high.12 The full scale score
was used. Snyder et al.12 report a mean score of 51.3
for a college sample.
Time 2 outcome measures
Positive mood was assessed using the Positive
and Negative Affect Scale (PANAS).17 The scale
consists of 20 words that describe positive and
negative emotions. These are self-rated for how
much they have been experienced in the last
week on a 5-point scale from ‘very slightly or not
at all’ to ‘extremely’. The PANAS has convergent
validity with measures such as the Hospital
Anxiety and Depression Scale.17 The positive
mood items were used with potential scores
between 10 and 50. Crawford and Henry17 report
a mean score of 32.06 for male participants in a
large normative general population sample.
General adjustment was assessed using the total
score for the general adjustment subscale of the
TAPES15 as described above. Five items are
rated on a 5-point scale from ‘strongly disagree’
to ‘strongly agree’ and include statements such as
‘I have adjusted to having an artificial limb’, ‘I feel
that I have dealt successfully with this trauma in
my life’, ‘I find it easy to talk about my artificial
limb’ etc. Potential scores were between 5 and 25.
Gallagher and MacLachlan15 report a mean score
of 18.87 for this subscale in a sample of 104 ampu-
tees studied for the development of the TAPES.
 Adjustment to amputation 1047

The data were analysed using SPSS version and rated their general health as 3.6 (SD 1.01) on a
15.00 (SPSS Inc., Chicago, IL, USA). Descriptive scale of 1–5 which equated to fair/good. Fifty-
data for the variables was examined. The main four participants (54.5%) reported other medical
research question was examined using two multi- problems including diabetes (N ¼ 19), back pain
ple regression analyses. Predictor variables (N ¼ 8), heart problems (N ¼ 7) and asthma
(phantom pain, age, gender, level and cause of (N ¼ 5).
amputation, social support and hope) were entered The main research question was examined by
into linear multiple regression models to establish entering data into two multiple regression ana-
their contribution to each outcome variable (posi- lyses. The necessary assumptions for regression
tive mood and general adjustment). of the data were met.18
Phantom pain intensity, age, gender (male or
Results female), level (transfemoral or transtibial) and
cause of amputation (‘chronic’ or ‘acute’), social
support (MSPSS) and hope (Hope Scale) were
Analyses showed that in terms of predictor vari- entered into the analyses. Thus the contribution
ables (phantom pain intensity, age, gender, level of each predictor variable to positive mood
and cause of amputation, social support and
(PANAS positive subscale) and general adjust-
hope) those not completing the study were not sta-
ment (TAPES general adjustment subscale) could
tistically different from those who did.
be determined. The analyses are presented in
The participants’ mean age was 60.7 years old
Tables 2 and 3.
(SD 13.3, range 19–91). Age was normally distrib-
It can be seen that hope is the only predictor
uted (Z ¼ 0.59, P ¼ 0.8). Sixteen participants were
variable making a significant individual
female (16.2%) and 83 were male (83.8%).
Fifty-four participants (54.5%) had transtibial
amputations and 45 (45.5%) had transfemoral Table 2 Multiple regression analysis for positive mood
(PANAS subscale)
amputations. No patients with knee disarticula-
tion were in the cohort. In terms of cause of the B SE B Beta
amputation, 42 (42.4%) were due to peripheral
vascular disorder, 26 (26.3%) due to diabetes, 18 (Constant) 1.945 9.589
Phantom intensity (TAPES) 0.334 0.830 0.04
(18.2%) due to accidents, 3 (3%) due to cancer, Age 0.020 0.073 0.03
and 9 (9.1%) to other acute causes. For the pur- Gender 1.705 2.457 0.07
poses of further analysis ‘cause’ was classified as Level of amputation 2.597 1.772 0.16
either ‘chronic’ (vascular and diabetes related) or Cause 0.427 2.085 0.02
MSPSS 0.080 0.060 0.15
‘acute’ (accident, cancer). In the case of one par- Hope Scale** 0.761 0.227 0.38
ticipant no cause was recorded.
The descriptive data for the study variables are TAPES, Trinity Amputation and Prosthetic Experiences Scale;
given in Table 1. MSPSS, Multidimensional Scale of Perceived Social Support;
Participants reported wearing their prosthesis PANAS, Positive and Negative Affect Scale.
on average 7.1 hours a day (SD 5.5, range 0–18) R2 ¼ 0.22 for model. **P50.001.

Table 1 Descriptive data for the study variables

Mean SD

Predictor variable Phantom pain intensity (TAPES) 1.71 0.85

Social Support (MSPSS) 5.6 1.29
Hope Scale 26.58 4.53
Outcome variable Positive affect (PANAS subscale) 33.33 8.29
General adjustment (TAPES subscale) 19.61 4.28

TAPES, Trinity Amputation and Prosthetic Experiences Scale; MSPSS, Multidimensional Scale of
Perceived Social Support; PANAS, Positive and Negative Affect Scale.
1048 J Unwin et al.
contribution to the prediction of positive mood.
The model accounts for 22% of the variance
in positive mood scores. Two variables make a
significant contribution to the prediction of
general adjustment; social support and hope. The
model accounts for 29% of the variance in general
adjustment.
Discussion
The main findings of the study are that initial
phantom pain, age, gender, level and cause of
amputation do not make a significant contribution
to outcome for lower limb amputees in relation to
positive mood and general adjustment, whereas
social support and hope do. This was in line with
the study predictions and has not previously been
demonstrated prospectively in relation to lower
limb amputees. In addition, it should be noted
that participants reported experiencing as much
positive affect as a student population17 and
were subjectively adjusted to the amputation to
the same extent as those on average eight years
post amputation,15 indicating that most indivi-
duals make a good early adjustment to the chal-
lenge of having a lower limb amputation.
Studying the full range of variables that have
been implicated in previous studies and taking a
positively framed conceptualization of adjustment
has clarified the relative importance of amputation
factors as compared to psychosocial factors in
positive psychological outcomes. Furthermore,
the current sample may be more representative
Table 3 Multiple regression analysis for general adjustment
(TAPES subscale)
B SE B Beta
(Constant) 5.153 4.826
Phantom intensity 0.006 0.512
Age 0.019 0.038
Gender 1.027 1.232
Level of amputation 0.805 0.897
Cause 0.652 1.064
Social support** 0.102 0.030
Hope Scale* 0.146 0.054
TAPES, Trinity Amputation and Prosthetic Experiences Scale.
R2 ¼ 0.29 for model. *P50.01, **P50.001.
of the outpatient lower limb amputee population
than previous prospective studies4,7 which were
carried out in a trauma centre and inpatient facil-
ity. Findings from previous studies could not nec-
essarily be seen as generalizable to other settings.
The current findings confirm the importance of
perceived social support in subjective adjustment
outcomes for amputees. Further research, both
quantitative and qualitative, is needed to illumi-
nate the mechanisms by which this effect occurs
so that we can use that knowledge to facilitate
adjustment. High levels of hope (a person’s
thoughts about their ability to see pathways to
goals and motivation to pursue them) are related
to more positive emotions and this has been shown
to play an important part in coping and the stress
process.13 It may be hypothesized that underlying
cognitive factors such as hope generate adaptive
behaviours including seeking social support and
goal striving, and this in turn leads to positive
mood and a sense of subjective adjustment.
Larger studies that can use statistical techniques
such as structural equation modelling may be
able to directly test such models. Intervention stu-
dies with ‘low hope’ individuals, perhaps using
group settings to capitalize on the social support
effect, would also be of interest.
Some weaknesses of the research should be kept
in mind. Ideally, the study would have recruited
103 participants but practical constraints meant
that this target was not met. The effect size in
the collected data between hope and the outcome
variables was large, however (0.44 and 0.39),
meaning the study was adequately powered.
Furthermore, the two previous prospective stu-
dies4,7 report data from 70 and 68 participants.
In addition, a longer follow-up or a further time
point would have been informative. Hanley et al.4
found stronger associations at two-year follow-up
between psychosocial variables (social support,
perceived control and catastrophizing) and out-
0.011 come (phantom pain and depression), compared
0.058 to one year. Singh et al. found that those respond-
0.087 ing at two- to three- year follow-up reported
0.094 increased levels of anxiety and depression.7 This
0.070
0.363
suggests that the effect of psychosocial variables
0.293 on adjustment may be further amplified over
time. A further issue is that although response
rates to the research were good and drop-out rel-
atively low, the sample is inevitably biased towards

patients who are better physically. Those too ill
for rehabilitation or who went on to need further
surgery were not included but form an important
proportion of lower limb amputees seen in reha-
bilitation services.
Previous studies have seemed to demonstrate a
link between pain and adjustment4 which at first
seems at odds with the current finding but is
explained by the differing conceptualizations of
adjustment. Previous studies have measured
depression or ‘negative’ emotional states. The cur-
rent study demonstrates the importance of also
studying positive adjustment which can seemingly
be achieved without reference to the experience of
phantom limb experiences where facilitating psy-
chosocial factors are present.
Although the experience of amputation is a sig-
nificant challenge, the current study shows that the
majority of people adjust well within a relatively
short time frame. This is a hopeful message for
those facing the experience and for their families.
The findings of the study suggest that services
should consider screening formally for psychoso-
cial variables at assessment so that they can target
scarce specialist resources at those who are iso-
lated and lower in hope. The protocol for the
study demonstrated that this could be done with
relatively little disruption to the usual clinical pro-
tocols. The social support and hope questionnaires
take a matter of minutes to complete. In addition,
the study reinforces the importance of services
incorporating interventions we know to enhance
hope and satisfaction with social support such as
‘buddy’ schemes where experienced limb users talk
to new patients, patient groups, collaborative goal
setting, etc. There is growing evidence that it is
possible to provide interventions that will increase
hopefulness.19 Delehanty and Trachsel20 report a
small study of a group intervention for amputees
aimed at building coping strategies. Treatment
group members were less distressed than a com-
parison group awaiting the programme. There is a
clear role for the presence of a clinical psychologist
in services for amputees to advise the team regard-
ing the psychological care of patients. The role
should involve overseeing appropriate screening
protocols, offering consultation and supervision
in relation to facilitating adjustment to amputa-
tion and delivering specific assessment and evi-
dence-based psychotherapeutic interventions for
Adjustment to amputation 1049
the small minority of patients who need them.
The ‘stepped care’ model recommended by the
National Institute for Clinical Excellence in rela-
tion to supportive and palliative care21 is one that
is very applicable in services for lower limb
amputees.
As clinicians and researchers we need to review
our assumptions about adjustment to amputation.
Previous efforts in both domains have focused on
pain and depression. This approach does not
account for the fact that both negative and posi-
tive emotion can coexist and that the latter is more
predictive of long-term adjustment.13 Distress in
the early phases of post-surgical recovery is a
common finding and there is even some evidence
that its presence can lead to better adjustment in
the medium to long term.22 A more positively
framed approach may help services to gain new
insights into the facilitation of psychological
adjustment to lower limb amputation.
Clinical messages
 We have found that, at six months, hope
contributes to positive mood and that both
hope and social support contribute to gen-
eral adjustment to lower limb amputation.
 We have found that, at six months, age,
gender, level, cause of amputation and initial
phantom pain are not related to positive
mood or general adjustment to lower limb
amputation.
Acknowledgements
With thanks to the patients and staff of Preston
Specialist Mobility Rehabilitation Centre, particu-
larly Kathryn Greenwood who helped with data
collection. The specialist nurse time for the study
was supported by a grant from the Research and
Development Department of Lancashire Teaching
Hospitals NHS Foundation Trust.
Contributors
JU initiated the study, monitored its progress,
collated and analysed the data and wrote the
paper. LK contributed to the study design,
1050 J Unwin et al.
the consenting of participants, data collection and
revisions of the paper. CC contributed to the study
design, advised on the analysis of the data and revi-
sions of the paper.
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