Clinical Rehabilitation 2009; 23: 1044–1050

A prospective study of positive adjustment tolower limb amputationJennifer Unwin University of Liverpool, Liverpool, Lynn Kacperek Lancashire Teaching Hospitals NHS Foundation Trust andChris 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

The amputation of a lower limb is a physical, emo-tional and social challenge for the patient, theirfamily and services aiming to assist them. Lowerlimb amputees have been shown to be compromised

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

pain,4 quality of life5 and anxiety and depression.6,7

The focus of the current study is psychologicaladjustment. A variety of factors have been studiedas potential predictors of adjustment outcome forpatients.6 Research has been mostly cross-sectionaland has yielded equivocal findings in relation to theimportance of demographic factors such as age,gender, level and cause of amputation.6 However,a recent UK study with a two- to three- yearfollow-up post inpatient rehabilitation found no

Address for correspondence: Jennifer Unwin, Division ofClinical Psychology, Whelan Building, University ofLiverpool, Liverpool L69 3GB, UK.e-mail: J.unwin@liverpool.ac.uk

� The Author(s), 2009.Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0269215509339001

association between age, gender or cause of ampu-tation and anxiety or depression.7

Most notably, there has been an exclusiveemphasis on studying ‘negative’ psychologicaladjustment outcomes, such as anxiety and depres-sion7 in prospective studies. Hanley et al.4 con-ducted a large prospective study of psychosocialpredictors of adjustment to lower limb amputationin the USA with phantom limb pain and depressivesymptoms as outcome measures. Social supportemerged as associated with less pain and depressionin their study, where initial levels of phantom painwere controlled for. They highlighted the impor-tance of future studies examining the predictorsof positive psychological well-being following ampu-tation because ‘positive and negative outcomes arenot mutually exclusive and are not merely oppositesides of the same domain’ (p.891). There has been aunidimensional conceptualization of psychologicaladjustment not only in studies with amputees todate but in illness research more generally.8

Research making clearer the characteristics ofthose who achieve better psychological outcomeswill provide useful information for rehabilitationservices aiming to promote adjustment to lowerlimb amputation. The current study thereforefocuses on the prediction of positive psychologicalwell-being following lower limb amputation.

Cross-sectional research has indicated that, inaddition 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 aresearcher in the field of positive psychology, hasshown that ‘hope’ can account for adjustment toadverse circumstances including acquired disabil-ity such as spinal cord injury and blindness.Snyder11 describes hope as a person’s stablethoughts about their ability to find ways to reachtheir goals and to find the motivation to pursuethose steps. While it is closely related to other cog-nitive factors (active problem-solving, optimism,perceived control and self-efficacy) Snyder andcolleagues have demonstrated that hope has dis-criminant validity beyond these other knowncorrelates of adjustment.12 There is an increasingemphasis on the importance of cognitive factors,such as hope, in the generation of positive copingprocesses and positive mood which are now

understood to underpin the process of adjustmentto a range of adverse circumstances including ill-ness and disability.13 Hope is measured using abrief questionnaire and is potentially easily under-stood by staff and patients alike. Thus, hope mayprovide researchers and clinicians with a parsimo-nious method for capturing the cognitive factorsassociated with psychological adjustment to lowerlimb amputation.

The current study addressed a number of theissues briefly raised above in relation to psycho-logical adjustment in lower limb amputees. Theresearch comprised a prospective study of bothdemographic and psychosocial variables in a rep-resentative sample of new lower limb amputees.Adjustment was conceptualized as the presenceof positive mood and a subjective rating of generaladjustment to the amputation as opposed to anabsence of anxiety or depression. It was hypothe-sized that initial phantom pain, age, gender, leveland cause of amputation would not be related topositive mood and general adjustment at follow-up but that social support and hope would be.

Methods

The research received approval from the localresearch ethics committee, the hospital trust’sresearch and development department and thecentre’s research committee.

Participants were recruited as a consecutivesample of new referrals to an outpatient specialistmobility and rehabilitation centre. All new lowerlimb amputees over the age of 18 were sent infor-mation sheets and invitations to take part in theresearch with their first appointment letter.Recruitment and follow-up took place over a24-month period. Planned exclusions were forpatients with significant cognitive impairmentbased on Hodkinson’s Mental Test14 or thosewho could not read and write English, as the ques-tionnaires were only available in this language.Patients were also excluded if they were toounwell 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 tocomplete and the nurse answered any questions.Patients were followed up after six months

Adjustment to amputation 1045

during routine appointments or by telephone bytheir specialist nurse. Two specialist nurses admi-nistered all the questionnaires. The data were ana-lysed by the first author. The mean time from firstassessment to follow-up was 6.8 months. A flow-chart illustrating the recruitment process is shownin 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 wereneeded for a multiple regression analysis withadequate power (0.8), given a medium effect size(0.15), seven predictors and a significance value setat 0.05. The final sample comprised 99 patients.

Time 1 predictor measuresPhantom pain intensity was assessed using the

pain subscale of the Trinity Amputation andProsthetic Experiences Scales (TAPES).15 Thisscale was developed to assess quality of life withlower limb amputees with regard to adjustment,restrictions, satisfaction with the prosthesis andpain. It has good face, construct and predictivevalidity.15 Phantom pain intensity ratings aregiven on a scale of mild to excruciating (1–5) forthe proceeding week. Phantom pain is described as‘pain in the part of the limb which wasamputated’.Self-reported levels of social support were

assessed using the Multidimensional Scale ofPerceived Social Support (MSPSS).16 This scalewas used in the one existing prospective study of

social support, adjustment and amputation in theUSA.4 The instrument has good internal and test–retest reliability16 and is a brief 12-item inventorywith a 7-point rating scale from ‘very strongly dis-agree’ to ‘very strongly agree’ with items coveringsupport from friends, family and significant others(potential scores between 7 and 84). The meantotal scale score was used (total score divided by12). Zimet et al.16 report a mean total scale scoreof 5.8 for a sample of undergraduates.

Hope was assessed using the Hope Scale.12 Thisscale has 12 items which are self-rated on an 8-pointscale from ‘definitely false’ to ‘definitely true’. Fouritems relate to ‘agency’ (goal-directed determina-tion) and four assess ‘pathways’ (planning waysto meet goals) and four items are fillers (potentialscores between 8 and 64). Internal reliability andtest–retest reliability are high.12 The full scale scorewas used. Snyder et al.12 report amean score of 51.3for a college sample.

Time 2 outcome measuresPositive mood was assessed using the Positive

and Negative Affect Scale (PANAS).17 The scaleconsists of 20 words that describe positive andnegative emotions. These are self-rated for howmuch they have been experienced in the lastweek on a 5-point scale from ‘very slightly or notat all’ to ‘extremely’. The PANAS has convergentvalidity with measures such as the HospitalAnxiety and Depression Scale.17 The positivemood items were used with potential scoresbetween 10 and 50. Crawford and Henry17 reporta mean score of 32.06 for male participants in alarge normative general population sample.

General adjustment was assessed using the totalscore for the general adjustment subscale of theTAPES15 as described above. Five items arerated 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 feelthat I have dealt successfully with this trauma inmy life’, ‘I find it easy to talk about my artificiallimb’ etc. Potential scores were between 5 and 25.Gallagher and MacLachlan15 report a mean scoreof 18.87 for this subscale in a sample of 104 ampu-tees studied for the development of the TAPES.

205 referrals to centre

141(69% of referrals)potential participants

120 (85% of potential)participants time 1

99 participants time 2(82.5% of time 1participants) mean timeto follow-up 6.8 months

64 patients excluded (31%)9 < 18 years old17 upper limb amputees20 transfer inpatients16 too ill1 dysphasic1 significant cognitiveimpairment

21 declined (15% ofpotential)

21 not followed up (17.5 %of time 1 participants)4 deceased6 too ill3 declined8 could not be contacted

Figure 1 Flowchart of the recruitment process.

1046 J Unwin et al.

The data were analysed using SPSS version15.00 (SPSS Inc., Chicago, IL, USA). Descriptivedata for the variables was examined. The mainresearch question was examined using two multi-ple regression analyses. Predictor variables(phantom pain, age, gender, level and cause ofamputation, social support and hope) were enteredinto linear multiple regression models to establishtheir contribution to each outcome variable (posi-tive mood and general adjustment).

Results

Analyses showed that in terms of predictor vari-ables (phantom pain intensity, age, gender, leveland cause of amputation, social support andhope) those not completing the study were not sta-tistically different from those who did.

The participants’ mean age was 60.7 years old(SD 13.3, range 19–91). Age was normally distrib-uted (Z¼ 0.59, P¼ 0.8). Sixteen participants werefemale (16.2%) and 83 were male (83.8%).Fifty-four participants (54.5%) had transtibialamputations and 45 (45.5%) had transfemoralamputations. No patients with knee disarticula-tion were in the cohort. In terms of cause of theamputation, 42 (42.4%) were due to peripheralvascular disorder, 26 (26.3%) due to diabetes, 18(18.2%) due to accidents, 3 (3%) due to cancer,and 9 (9.1%) to other acute causes. For the pur-poses of further analysis ‘cause’ was classified aseither ‘chronic’ (vascular and diabetes related) or‘acute’ (accident, cancer). In the case of one par-ticipant no cause was recorded.

The descriptive data for the study variables aregiven in Table 1.

Participants reported wearing their prosthesison average 7.1 hours a day (SD 5.5, range 0–18)

and rated their general health as 3.6 (SD 1.01) on ascale of 1–5 which equated to fair/good. Fifty-four participants (54.5%) reported other medicalproblems including diabetes (N¼ 19), back pain(N¼ 8), heart problems (N¼ 7) and asthma(N¼ 5).

The main research question was examined byentering data into two multiple regression ana-lyses. The necessary assumptions for regressionof the data were met.18

Phantom pain intensity, age, gender (male orfemale), level (transfemoral or transtibial) andcause of amputation (‘chronic’ or ‘acute’), socialsupport (MSPSS) and hope (Hope Scale) wereentered into the analyses. Thus the contributionof each predictor variable to positive mood(PANAS positive subscale) and general adjust-ment (TAPES general adjustment subscale) couldbe determined. The analyses are presented inTables 2 and 3.

It can be seen that hope is the only predictorvariable making a significant individual

Table 1 Descriptive data for the study variables

Mean SD

Predictor variable Phantom pain intensity (TAPES) 1.71 0.85Social Support (MSPSS) 5.6 1.29Hope Scale 26.58 4.53

Outcome variable Positive affect (PANAS subscale) 33.33 8.29General adjustment (TAPES subscale) 19.61 4.28

TAPES, Trinity Amputation and Prosthetic Experiences Scale; MSPSS, Multidimensional Scale ofPerceived Social Support; PANAS, Positive and Negative Affect Scale.

Table 2 Multiple regression analysis for positive mood(PANAS subscale)

B SE B Beta

(Constant) 1.945 9.589Phantom intensity (TAPES) 0.334 0.830 0.04Age �0.020 0.073 �0.03Gender 1.705 2.457 0.07Level of amputation 2.597 1.772 0.16Cause �0.427 2.085 �0.02MSPSS 0.080 0.060 0.15Hope Scale** 0.761 0.227 0.38

TAPES, Trinity Amputation and Prosthetic Experiences Scale;MSPSS, Multidimensional Scale of Perceived Social Support;PANAS, Positive and Negative Affect Scale.R2¼0.22 for model. **P50.001.

Adjustment to amputation 1047

contribution to the prediction of positive mood.The model accounts for 22% of the variancein positive mood scores. Two variables make asignificant contribution to the prediction ofgeneral adjustment; social support and hope. Themodel accounts for 29% of the variance in generaladjustment.

Discussion

The main findings of the study are that initialphantom pain, age, gender, level and cause ofamputation do not make a significant contributionto outcome for lower limb amputees in relation topositive mood and general adjustment, whereassocial support and hope do. This was in line withthe study predictions and has not previously beendemonstrated prospectively in relation to lowerlimb amputees. In addition, it should be notedthat participants reported experiencing as muchpositive affect as a student population17 andwere subjectively adjusted to the amputation tothe same extent as those on average eight yearspost 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 apositively framed conceptualization of adjustmenthas clarified the relative importance of amputationfactors as compared to psychosocial factors inpositive psychological outcomes. Furthermore,the current sample may be more representative

of the outpatient lower limb amputee populationthan previous prospective studies4,7 which werecarried 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 ofperceived social support in subjective adjustmentoutcomes for amputees. Further research, bothquantitative and qualitative, is needed to illumi-nate the mechanisms by which this effect occursso that we can use that knowledge to facilitateadjustment. High levels of hope (a person’sthoughts about their ability to see pathways togoals and motivation to pursue them) are relatedto more positive emotions and this has been shownto play an important part in coping and the stressprocess.13 It may be hypothesized that underlyingcognitive factors such as hope generate adaptivebehaviours including seeking social support andgoal striving, and this in turn leads to positivemood and a sense of subjective adjustment.Larger studies that can use statistical techniquessuch as structural equation modelling may beable to directly test such models. Intervention stu-dies with ‘low hope’ individuals, perhaps usinggroup settings to capitalize on the social supporteffect, would also be of interest.

Some weaknesses of the research should be keptin mind. Ideally, the study would have recruited103 participants but practical constraints meantthat this target was not met. The effect size inthe collected data between hope and the outcomevariables 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 timepoint would have been informative. Hanley et al.4

found stronger associations at two-year follow-upbetween psychosocial variables (social support,perceived control and catastrophizing) and out-come (phantom pain and depression), comparedto one year. Singh et al. found that those respond-ing at two- to three- year follow-up reportedincreased levels of anxiety and depression.7 Thissuggests that the effect of psychosocial variableson adjustment may be further amplified overtime. A further issue is that although responserates to the research were good and drop-out rel-atively low, the sample is inevitably biased towards

Table 3 Multiple regression analysis for general adjustment(TAPES subscale)

B SE B Beta

(Constant) 5.153 4.826Phantom intensity �0.006 0.512 �0.011Age �0.019 0.038 �0.058Gender 1.027 1.232 0.087Level of amputation �0.805 0.897 �0.094Cause 0.652 1.064 0.070Social support** 0.102 0.030 0.363Hope Scale* 0.146 0.054 0.293

TAPES, Trinity Amputation and Prosthetic Experiences Scale.R2¼ 0.29 for model. *P50.01, **P50.001.

1048 J Unwin et al.

patients who are better physically. Those too illfor rehabilitation or who went on to need furthersurgery were not included but form an importantproportion of lower limb amputees seen in reha-bilitation services.

Previous studies have seemed to demonstrate alink between pain and adjustment4 which at firstseems at odds with the current finding but isexplained by the differing conceptualizations ofadjustment. Previous studies have measureddepression or ‘negative’ emotional states. The cur-rent study demonstrates the importance of alsostudying positive adjustment which can seeminglybe achieved without reference to the experience ofphantom limb experiences where facilitating psy-chosocial factors are present.

Although the experience of amputation is a sig-nificant challenge, the current study shows that themajority of people adjust well within a relativelyshort time frame. This is a hopeful message forthose facing the experience and for their families.The findings of the study suggest that servicesshould consider screening formally for psychoso-cial variables at assessment so that they can targetscarce specialist resources at those who are iso-lated and lower in hope. The protocol for thestudy demonstrated that this could be done withrelatively little disruption to the usual clinical pro-tocols. The social support and hope questionnairestake a matter of minutes to complete. In addition,the study reinforces the importance of servicesincorporating interventions we know to enhancehope and satisfaction with social support such as‘buddy’ schemes where experienced limb users talkto new patients, patient groups, collaborative goalsetting, etc. There is growing evidence that it ispossible to provide interventions that will increasehopefulness.19 Delehanty and Trachsel20 report asmall study of a group intervention for amputeesaimed at building coping strategies. Treatmentgroup members were less distressed than a com-parison group awaiting the programme. There is aclear role for the presence of a clinical psychologistin services for amputees to advise the team regard-ing the psychological care of patients. The roleshould involve overseeing appropriate screeningprotocols, offering consultation and supervisionin relation to facilitating adjustment to amputa-tion and delivering specific assessment and evi-dence-based psychotherapeutic interventions for

the small minority of patients who need them.The ‘stepped care’ model recommended by theNational Institute for Clinical Excellence in rela-tion to supportive and palliative care21 is one thatis very applicable in services for lower limbamputees.

As clinicians and researchers we need to reviewour assumptions about adjustment to amputation.Previous efforts in both domains have focused onpain and depression. This approach does notaccount for the fact that both negative and posi-tive emotion can coexist and that the latter is morepredictive of long-term adjustment.13 Distress inthe early phases of post-surgical recovery is acommon finding and there is even some evidencethat its presence can lead to better adjustment inthe medium to long term.22A more positivelyframed approach may help services to gain newinsights into the facilitation of psychologicaladjustment to lower limb amputation.

Clinical messages

� We have found that, at six months, hopecontributes to positive mood and that bothhope 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 initialphantom pain are not related to positivemood or general adjustment to lower limbamputation.

AcknowledgementsWith thanks to the patients and staff of Preston

Specialist Mobility Rehabilitation Centre, particu-larly Kathryn Greenwood who helped with datacollection. The specialist nurse time for the studywas supported by a grant from the Research andDevelopment Department of Lancashire TeachingHospitals NHS Foundation Trust.

ContributorsJU initiated the study, monitored its progress,

collated and analysed the data and wrote thepaper. LK contributed to the study design,

Adjustment to amputation 1049

the consenting of participants, data collection andrevisions of the paper. CC contributed to the studydesign, advised on the analysis of the data and revi-sions of the paper.

References

1 Geertzen JHB, Martina JD, Rietman HS. Lowerlimb amputation part 2: rehabilitation–a 10 yearliterature review. Prosthet Orthot Int 2001; 2:14–20.

2 Fisher K, Hanspal RS, Marks L. Return to workafter lower limb amputation. Int J Rehabil Res2003; 26: 51–56.

3 Murray CD, Fox J. Body image and prosthesis sat-isfaction in the lower limb amputee. DisabilRehabil 2002; 24: 925–31.

4 Hanley MA, Jensen MP, Ehde DM, Hoffman AJ,Patterson DR, Robinson LR. Psychosocialpredictors of long-term adjustment to lower-limbamputation and phantom limb pain. DisabilRehabil 2004; 26: 882–93.

5 Demet K, Martinet N, Guillemin F, Paysant J,Andre, J. Health related quality of life and relatedfactors in 539 persons with amputation of upperand lower limb. Disabil Rehabil 2003; 25: 480–86.

6 Horgan O, MacLachlan M. Psychosocial adjust-ment to lower-limb amputation: a review. DisabilRehabil 2004; 26: 837–50.

7 Singh R, Riply D, Pentland B et al. Depression andanxiety symptoms after lower limb amputation: therise and fall. Clin Rehabil 2009; 23: 281–86.

8 Bishop M. Quality of life and psychosocialadaptation to chronic illness and acquireddisability: a conceptual and theoretical synthesis.J Rehabil 2005; 71: 5–13.

9 Livneh H, Antonak RF, Gerhardt J.Multidimensional investigation of the structureof coping among people with amputations.Psychosomatics 2000; 41: 235–44.

10 Dunn DS. Well-being following amputation:salutary effects of positive meaning, optimism,and control. Rehabil Psychol 1996; 41: 285–302.

11 Snyder CR. Hope theory: rainbows in the mind.Psychol Inq 2002; 13: 249–75.

12 Snyder CR, Harris C, Anderson JR et al. The willand the ways: Development and validation of anindividual-differences measure of hope. J Pers SocPsychol 1991; 60: 570–85.

13 Folkman S. The case for positive emotions inthe stress process. Anxiety Stress Coping 2008;21: 3–14.

14 Kane RA, Kane RL. Assessing the elderly, apractical guide to measurement. Toronto,Lexington Books, 1985.

15 Gallagher P, MacLachlan M. Development andpsychometric evaluation of the TrinityAmputation and Prosthesis ExperienceScales (TAPES). Rehabil Psychol 2000; 45:130–54.

16 Zimet GD, Dahlem NW, Zimet SG, Farely GK.The multidimensional scale of perceived socialsupport. J Pers Assess 1988; 52: 30–41.

17 Crawford JR, Henry DH. The positive andnegative affect schedule (PANAS): constructvalidity, measurement properties and normativedata in a large non-clinical sample. Br J ClinPsychol 2004; 4: 245–65.

18 Field A. Discovering statistics using SPSS.London, Sage, 2005.

19 Linley P, Joseph S. Positive Psychology inPractice. Hoboken, NJ, Wiley, 2004.

20 Delehanty R, Trachsel L. Effects of short-termgroup treatment on rehabilitation outcome ofadults with amputations. Int J Rehabil Health1995; 1: 61–74.

21 NICE Guidance. Supportive and Palliative Care.London, National Institute for ClinicalExcellence, 2004.

22 Salmon P. Psychological factors in surgicalstress: implications for management. Clin PsycholRev 1992; 12: 681–704.

1050 J Unwin et al.