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VOLUME 5, ISSUE 1 

 2022 

 

RESEARCH ARTICLE 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics 

Journal. 2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

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1 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

 

 

 
RESEARCH ARTICLE 

 

A PSYCHOSOCIAL ADJUSTMENT MEASURE FOR PERSONS WITH UPPER LIMB AMPUTATION 

Resnik L.J. 1,2*, Ni P. 3, Borgia M.L. 1, Clark M.A. 2,4 
 
1 Research Department, Providence VA Medical Center, Providence, USA. 
2 Department of Health Services, Policy and Practice, Brown University, Providence, USA. 
3 Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, USA. 
4 Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Massachusetts, USA.  

 

 

 

 

  

 

 

 

 

 

 

 

 
 

 

 

INTRODUCTION   

Individuals experiencing limb loss undergo social and 

psychological adjustment as well as physical adjustment.1-4 

Psychosocial adjustment is a process that may involve 

changes in body image, personal identity, lifestyle and daily 

functioning.5  Psychosocial adjustment can be  affected  by  

 

 

 

clinical conditions.  A substantial proportion of persons with 

upper limb amputation experience clinical depression (20-

55%),1,6,7 post-traumatic stress disorder (23–24%),1,6 

anxiety (36%),5 and long term post-traumatic psychological 

distress (25%) after amputation.8 More than 20% have other 

co-occurring conditions.6 Levels of depression and anxiety 

are greater and psychosocial adjustment poorer in persons 

with upper limb amputation (ULA) as compared to those 

with lower limb amputation,9 perhaps due to the visibility of 

the upper limb and difficulty covering a prosthesis under 

clothing. Persons with upper limb amputation report an 

ongoing awareness of difference in appearance,10 as well 

 
OPEN  ACCESS Volume 5, Issue 1, Article No.8. 2022 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

BACKGROUND: Measurement of psychosocial adjustment after upper limb amputation (ULA) could be 

helpful in identifying persons who may benefit from interventions, such as psychotherapy and/or support 

groups. However, available measures of psychosocial adjustment after limb loss are currently designed 

for prosthetic users only. 

OBJECTIVE: To create a measure of psychosocial adjustment for persons with ULA that could be 

completed by individuals regardless of whether a prosthesis is use. 

METHODOLOGY: We modified items from an existing Trinity Amputation and Prosthesis Experience 

Survey (TAPES) measure and generated new items pertinent to persons who did not use a prosthesis. 

Item content was refined through cognitive interviewing and pilot testing. A telephone survey of 727 

persons with major ULA (63.6% male, mean age of 54.4) was conducted after pilot-testing. After 

exploratory and confirmatory factor analyses (EFA and CFA), Rasch analyses were used to evaluate 

response categories, item fit and differential item functioning (DIF). Item-person maps, score 

distributions, and person and item reliability were examined. Test-retest reliability was evaluated in a 

50-person subsample.  

FINDINGS: EFA and CFA indicated a two-factor solution. Rasch analyses resulted in a 7-item 

Adjustment to Limitation subscale (CFI=0.96, TLI=0.95, RMSEA=0.128) and a 9-item Work and 

Independence subscale (CFI=0.935, TLI=0.913, RMSEA=0.193). Cronbach alpha and ICC were 0.82 

and 0.63 for the Adjustment to Limitation subscale and 0.90 and 0.80 for the Work and Independence 

subscale, respectively. 

CONCLUSIONS: This study developed the Psychosocial Adjustment to Amputation measure, which 

contains two subscales: 1) Adjustment to Limitation and 2) Work and Independence. The measure has 

sound structural validity, good person and item reliability, and moderate to good test-retest reliability.  

ARTICLE INFO 

Received: December 17, 2021 

Accepted: March 10, 2022  

Published: April 5, 2022 

CITATION 

Resnik L.J., Ni P., Borgia M.L., 

Clark M.A. A psychosocial 

adjustment measure for persons 

with upper limb amputation. 

Canadian Prosthetics & Orthotics 

Journal. 2022; Volume 5, Issue 1, 

No.8.https://doi.org/10.33137/cpoj.

v5i1.37873 

KEYWORDS 

Upper Limb Amputation, Upper 

Limb Prosthesis, Psychosocial 

Adjustment, Factor Analysis, 

Rasch Analysis, Psychometrics, 

Prosthesis  

* CORRESPONDING AUTHOR 

Linda J. Resnik PT, PhD 

Research Department, Providence VA Medical Center, 830 
Chalkstone Ave, Building 32, Providence, RI 02908 

E-Mail: Linda.Resnik@va.gov 

ORCID ID: https://orcid.org/0000-0002-0168-6759 

https://doi.org/10.33137/cpoj.v5i1.37873
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v5i1.37873
https://doi.org/10.33137/cpoj.v5i1.37873
mailto:Linda.Resnik@va.gov
https://orcid.org/0000-0002-0168-6759


 

2 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
as high levels of body image anxiety and social insecurity 

that may impact their relationships.11 Coping strategies, 

social support, social discomfort, perceived social stigma, 

and self-consciousness in public are associated with 

adjustment to amputation.5,12 

While several earlier studies utilized qualitative methods 

 to understand psychosocial adjustment after limb 

loss,10,11,13-15 few studies have used quantitative measures 

of psychosocial adjustment. Studies that did use 

quantitative measures have been limited to prosthesis 

users.5,9,16,17 Measurement of psychosocial adjustment 

could be helpful in identifying persons who might benefit 

from interventions such as psychotherapy and/or support 

groups. Further, repeated measures of psychosocial 

adjustment may be needed to understand the experiences 

and needs of persons with limb loss, given that that 

adjustment to limb loss is a process that occurs over time.13   

Unfortunately, to date, there are no measures of 

psychosocial adjustment that can be used by all persons 

with ULA. While measures such as the psychosocial 

adjustment scale of the Trinity Amputation and Prosthesis 

Experience Survey (TAPES) exist, this measure specifically 

targets psychosocial adaptation to prosthesis use. The 

majority of items in this scale refer to use of “an artificial 

limb”, making it inappropriate for persons with amputation 

who do not use a prosthesis. Given the prevalence of 

prosthesis abandonment in ULA (estimated to be between 

20-40%),18,19 a measure that can be completed by 

prosthetic users as well as non-users is needed. Thus, the 

purpose of this study was to create a measure of 

psychosocial adjustment for persons with ULA that could be 

completed by individuals regardless of prosthesis use. 

METHODOLOGY 

We modified items from the TAPES measure, identified new 

items, and refined this new item set through cognitive 

testing and pilot testing. The original TAPES instrument is 

comprised of three sections (psychosocial adjustment, 

activity restriction, and satisfaction with prosthesis), each of 

which contains one or more individually scored subscales, 

with 15 items related to adjustment.20,21 While the TAPES 

was originally developed for persons with lower limb 

amputation, the TAPES-ULA was suggested for use in 

persons with upper limb loss.22 The TAPES-ULA, eliminates 

the item, “I don’t care if anyone notices I am limping” due to 

lack of relevance for persons with upper limb loss. Twelve 

of the 14 remaining TAPES-ULA items specifically mention 

the use of an artificial limb. We first made some changes to 

the original TAPES-ULA items. We changed terminology, 

replacing the word “amputation” with the words “limb 

difference”, to be more inclusive of persons with congenital 

limb difference. Two items had similar content, “I don’t mind 

people asking me about my artificial limb, and I have 

difficulty in talking about my limb loss in conversation”, 

therefore we selected the item that could be completed 

regardless of prosthesis use. We then added 6 new items 

that could be completed by both users and non-users of 

prostheses. The new items were: “I have adjusted to being 

an amputee”, “I don’t care if somebody looks at my residual 

arm”, “My amputation interferes with the ability to do my 

work”, “Having an amputation makes me more dependent 

on others than I would like to be”, “Having an amputation 

limits the kind of work that I can do”, and “Having an 

amputation limits the amount of work that I can do.”   

We then administered the item set in cognitive interviews 

and utilized the feedback to iteratively refine the items and 

instructions. Cognitive interviewing is an approach 

commonly used to enhance validity of item content and 

response processes.23 Cognitive interviews were 

conducted with 11 participants with ULA (9 prosthesis 

users, 2 non-user). The sample was 63.6% male, with a 

mean age 54.4 years (Table 1). During these interviews, 

participants were asked to think out loud as they answered 

the items and to identify any instructions or words that were 

confusing as well as any questions that were difficult to 

answer.24,25 

Table 1: Characteristics of the cognitive testing and pilot study 

samples. 

 

  

 
Cognitive, 

N=11 
Pilot,  
N=20 

Age, Mean (SD) 54.4 (9.8) 61.9 (13.5) 

Gender, N (%)   

   Male 7 (63.6) 11 (55.0) 

   Female 4 (36.4) 9 (45.0) 

Amputation level, N (%)   

  Transradial/wrist disarticulation 5 (45.5) 11 (55.0) 

   Transhumeral/elbow disarticulation 6 (54.6) 5 (25.0) 

   Shoulder 0 (0.0) 4 (20.0) 

   Bilateral upper limb loss 1 (9.1) 4 (20.0) 

Prosthesis User, N (%) 9 (81.8) 15 (75.0) 

Primary prosthesis type, N (%)   

   Body powered 6 (66.7) 6 (40.0) 

   Myoelectric 2 (22.2) 6 (40.0) 

   Hybrid 0 (0.0) 1 (6.7) 

   Cosmetic 1 (11.1) 1 (6.7) 

   Sports/recreation 0 (0.0) 1 (6.7) 

Etiology, N (%)   

   Combat injury 0 (0.0) 2 (10.0) 

   Accident 2 (27.3) 10 (50.0) 

   Burn  1 (9.1) 2 (10.0) 

   Cancer 1 (9.1) 1 (5.0) 

   Diabetes 0 (0.0) 0 (0.0) 

   Infection 1 (9.1) 2 (10.0) 

   Congenital 3 (27.3) 5 (25.0) 

   Other 2 (18.2) 2 (10.0) 

Race, N (%)   

     White 10 (90.9) 14 (77.8) 

     Black 1 (9.1) 1 (5.6) 

     Other 0 (0.0) 3 (16.7) 

https://doi.org/10.33137/cpoj.v5i1.37873


 

3 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
As a result of feedback obtained in the cognitive interviews, 

we replaced the word “residual limb” with the word “stump”, 

because some respondents in the cognitive interviews told 

us that this was the terminology that they used most often 

to refer to their residuum. We also replaced the term 

“artificial limb” with the term “prosthesis” because we found 

that was more commonly used in our sample. We tested the 

use of the terms “amputation”, “amputee”, and “limb 

difference.” Because participants with congenital limb 

difference in our sample did not express any concerns about 

use of the term “amputation” in some items, we retained that 

language in new items. At the end of cognitive testing, we 

had a 19-item set. Ten items were specific to prosthesis 

users, and 9 were pertinent to prosthesis users as well as 

non-users.  

Next, we discussed the measure and instructions with the 

survey team, who provided feedback based on their prior 

experiences interviewing individuals with ULA. As a result, 

we revised the instructions for bilateral participants who 

were prosthetic users, updating them to refer to the 

prostheses “on either side” instead of “on your dominant 

side.” We also changed the wording of the response options 

so that the middle of the scale was “neither disagree nor 

agree” (rather than “neither agree nor disagree”) to match 

the directionality of responses within the original 

psychosocial adjustment TAPES scales. The refined item-

set and instructions were then pilot tested in a convenience 

sample of 20 participants (5 non-users and 15 prosthesis 

users, 4 persons with bilateral limb loss, 55% male, mean 

age 61.9) (Table 1). No revisions were made to the items or 

instructions after pilot testing. The final instrument, which 

was administered in a telephone survey to 727 participants, 

is shown in APPENDIX A. 

A subgroup of 50 persons (the reliability sample) completed 

the telephone survey two times within one week. 

Sample and recruitment 

Participants were included if they had amputation at the 

level of the wrist or above and were able to understand 

study requirements and hear well enough to comprehend 

questions administered over the telephone. Participants for 

all phases of the study (cognitive interviews, pilot testing 

and field testing) were recruited from several sources: an 

earlier study conducted in the Department of Veterans 

Affairs (VA), a list of veterans who had received VA care 

between January 1, 2016 – June 1, 2019, eblasts sent from 

the Amputation Coalition of America, and recruitment letters 

sent from a private prosthetics care company. The study 

was approved by VA Central institutional review board, and 

all participants gave oral informed consent as approved by 

the IRB.  

Data analysis overview 

Characteristics of the field study sample were described. To 

evaluate structural validity of the measure, we performed 

exploratory and confirmatory analyses using data from the 

first 351 persons (subsample 1) and final confirmatory 

analyses using data from the subsequent 376 respondents 

(subsample 2). We then used data from the entire sample 

to develop Rasch partial credit models and evaluated item 

fit statistics, item category curves, and the presence of 

differential item functioning (DIF). We also evaluated item-

person maps, score distributions, and person and item 

reliability. Finally, we examined test-retest reliability using a 

convenience subgroup of 50 persons who completed the 

telephone survey two times within two weeks. These 

persons were selected based on amputation level and 

laterality to ensure representation across these key 

characteristics. 

Factor analyses 

The dimensionality of the item pool was evaluated using 

exploratory factor analysis (EFA) and confirmatory factor 

analysis (CFA). In the EFA analysis, we utilized factor 

loadings, eigenvalues, and percentage of variance 

explained by the first factor to assess unidimensionality for 

the full 19-item measure. We determined the number of 

unidimensional factors by identifying the number of 

eigenvalues > 1 and applying parallel analysis.26 We 

assessed CFA model fit using the comparative fit index 

(CFI), Tucker–Lewis Index (TLI), root mean square error 

approximation (RMSEA), and residual correlations. EFA 

and CFA analyses were conducted with M-Plus software.27  

We considered CFI and TLI values of 0.90 or higher and 

RMSEA values <0.08 as acceptable model indices. After 

examining the model fit for all item combinations, we 

selected the optimal models that retained the most items 

with acceptable model fit. We evaluated local independence 

by inspecting the residual correlations between items; items 

with residual correlations greater than 0.2 were considered 

to have local dependence.28-30 

We then performed CFA using data from subsample 2. Fit 

criteria used in final confirmatory factor analyses were 

similar to those used in exploratory analyses. However, 

rather than using a stringent RMSEA criteria, we focused on 

examining the residual correlations and eigenvalue ratios 

rather than on the RMSEA value. We did this because 

RMSEA is sensitive to the weight matrix, which is used in 

the Chi-square calculation; a small change in the weight 

matrix (e.g. different samples) could cause large changes in 

RMSEA.  

Rasch Partial Credit Modeling and DIF Evaluation  

Rasch analyses involve probabilistic modeling of a latent 

trait, where persons and items are measured on the same 

interval scale; the Rasch framework allows assessment of 

psychometric properties for the development and 

refinement of measures.31,32 Rasch partial credit modeling 

of data from the entire sample was used to evaluate 

monotonicity, residual variance explained, item fit statistics, 

https://doi.org/10.33137/cpoj.v5i1.37873
https://www.va.gov/
https://www.va.gov/
https://www.amputee-coalition.org/


 

4 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
 

 

 

 

 

 

Table 2: Characteristics of the field study sample. 

 

 Subsample 1 
 (N=351) 

Subsample 2 
 (N=376) 

Full Sample 
(N=727)  

Test-retest 
Sample (N=50) 

Age- Mean (SD) 64.0 (12.9) 58.7 (15.8) 61.2 (14.8) 61.1 (14.2) 

Time since amputation- Mean (SD) 33.1 (18.4) 23.4 (19.7) 28.4 (19.6) 31.7 (19.7) 

Status-N (%)      

 Veteran 334 (95.2) 216 (57.8) 550 (75.9) 47 (94.0) 

 Military 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 

 Civilian 17 (4.8) 157 (42.0) 174 (24.0) 3 (6.0) 

 Unknown 0 (0.0) 1 (0.3) 1 (0.1) 0 (0.0) 

Sex-N (%)     

 Female 10 (2.9) 142 (37.8) 152 (20.9) 2 (4.0) 

 Male 341 (97.2) 234 (62.2) 575 (79.1) 48 (96.0) 

Race-N (%)     

 White 284 (80.9) 313 (83.2) 597 (82.1) 40 (80.0) 

 Black 34 (9.7) 32 (8.5) 66 (9.1) 2 (4.0) 

 Unknown 20 (5.7) 19 (5.1) 39 (5.4) 6 (12.0) 

 Mixed 13 (3.7) 12 (3.2) 25 (3.4) 2 (4.0) 

Amputation level-N (%)     

 Shoulder 42 (12.0) 33 (8.8) 75 (10.3) 10 (20.0) 

 Transhumeral 129 (36.8) 97 (25.8) 226 (31.1) 15 (30.0) 

 Transradial 180 (51.3) 203 (54.0) 383 (52.7) 15 (30.0) 

 Bilateral 0 (0.0) 43 (11.4) 43 (5.9) 10 (20.0) 

Etiology-N (%)     

 Combat 102 (29.1) 55 (17.2) 157 (23.4) 16 (32.0) 

 Accident 237 (67.5) 204 (63.7) 441 (65.7) 31 (62.0) 

 Burn  34 (9.7) 35 (10.9) 69 (10.3) 9 (18.0) 

 Cancer  15 (4.3) 29 (9.1) 44 (6.6) 3 (6.0) 

 Diabetes 3 (0.9) 1 (0.3) 4 (0.6) 0 (0.0) 

 Infection / other health problem 35 (10.0) 71 (22.2) 106 (15.8) 7 (14.0) 

 Congenital 0 (0.0) 56 (14.9) 56 (7.0) 0 (0.0) 

Current prosthesis user- N (%)     

  Yes 211 (60.1) 261 (69.4) 472 (64.9) 50 (100.0) 

  No 140 (39.9) 115 (30.6) 255 (35.1) 0 (0.0) 

USERS      

Primary prosthesis type- N (%)     

 Body-powered 155 (73.5) 155 (59.4) 310 (65.7) 41 (82.0) 

 Myoelectric 44 (20.9) 72 (27.6) 116 (24.6) 6 (12.0) 

 Hybrid 0 (0.0) 4 (1.5) 4 (0.9) 0 (0.0) 

 Cosmetic 8 (3.8) 20 (7.7) 28 (5.9) 2 (4.0) 

 Sport 4 (1.9) 6 (2.3) 10 (2.1) 1 (2.0) 

 Unknown 0 (0.0) 4 (1.5) 5 (0.9) 0 (0.0) 

Hours of daily prosthesis use- N (%)     

  Less than 2 hours 40 (19.1) 45 (17.6) 85 (18.2) 9 (18.0) 

  2 to less than 4 hours 28 (13.3) 26 (10.1) 54 (11.6) 12 (24.0) 

  4 to less than 8 hours 38 (18.1) 37 (14.4) 75 (16.1) 5 (10.0) 

  8 to less than 12 hours 43 (20.5) 62 (24.1) 105 (22.5) 10 (20.0) 

  12 hours or more 61 (29.1) 87 (33.9) 148 (31.7) 14 (28.0) 

 

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5 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
item category curves, and the presence of any differential 

item functioning (DIF). We removed items with “moderate to 

large” DIF (> 0.64) as defined by Zwick.33  

Item-person maps and reliability 

We used Rasch item-person maps for each factor to 

evaluate how the range and position of item measure 

distributions corresponded to the range and position of the 

person score generated from all items within the factor. We 

evaluated person reliability (ability to discriminate between 

persons, or traditional test reliability) as well as item 

reliability using Rasch models. The test information function 

was used to determine the ranges of person scores with 

reliability ≥ 0.9 and ≥ 0.8. Given the smaller number of items 

completed by non-prosthesis users, we repeated person 

reliability analyses in the sub-sample that did not utilize a 

prosthesis. Cronbach’s alpha was used to assess internal 

consistency of the final factors.  

Transformation and scoring 

Rasch summary scores were calculated on a logit scale for 

the final item set. Person logit scores were then 

standardized into a T-score matrix, and conversion scoring 

tables were created (for those with no missing data).  

Test-retest reliability and calculation of minimal 

detectable change 

Fifty participants completed the phone survey twice within 2 

weeks (mean 7.8 (SD 3.0), range 3-14 days). These data 

were used to assess test-retest reliability via the Shrout and 

Fleiss intraclass correlation coefficient (ICC) type 3,1. We 

calculated minimal detectable change (MDC) at 90% and 

95% confidence levels using the ICC and pooled standard 

deviation of factor scores (at interviews 1 and 2).  

RESULTS 

Characteristics of participants in subsample 1, subsample 

2, and the test-retest reliability sample are shown in Table 2. 

The item pool utilized in field testing, items not retained, and 

items in the final Psychosocial Adjustment to Amputation 

measure are shown in Table 3. All decisions for dropping 

items as a result of EFA and CFA analyses are shown in the  

Figure 1 flow chart.  

Factor analyses 

EFA fit indices for a one-factor solution were not acceptable 

(CFI=0.83, TLI=0.80, RMSEA=0.15) and eigenvalue ratios 

for the first and second factor solutions did not suggest a 

unidimensional scale (9.28/2.84 <4).  

Table 3: The item pool utilized in field testing, items not retained and items in the final modified Psychosocial Adjustment to Amputation 
subscales. Note: Italicized text indicates items limited to prosthesis users.  
 

Items used in field testing 
Item 
Dropped 

Final 2-factor satisfaction scales 

  Factor 1: Adjustment to Limitation 

I have adjusted to having a prosthesis  I have adjusted to having a prosthesis 

As time goes by, I accept my prosthesis more  As time goes by, I accept my prosthesis more 

I feel that I have dealt successfully with this trauma in my life  I feel that I have dealt successfully with this trauma in my life 

Although I have an artificial limb, my life is full  Although I have an artificial limb, my life is full 

I have gotten used to wearing a prosthesis  I have gotten used to wearing a prosthesis 

I don't care if somebody looks at my prosthesis  X  

I find it easy to talk about my prosthesis  I find it easy to talk about my prosthesis 

I have difficulty in talking about my limb loss in conversation  X  

I have adjusted to being an amputee   I have adjusted to being an amputee  

I don't care if somebody looks at my stump X  

  Factor 2: Work and Independence 

A prosthesis interferes with the ability to do my work  A prosthesis interferes with the ability to do my work 

Having a prosthesis makes me more dependent on others 
than I would like to be 

 
Having a prosthesis makes me more dependent on others than I 
would like to be 

Having a prosthesis limits the kind of work that I can do  Having a prosthesis limits the kind of work that I can do 

Being someone with a limb difference means that I can't do 
what I want to do 

 
Being someone with a limb difference means that I can't do what 
I want to do 

Having a prosthesis limits the amount of work that I can do  Having a prosthesis limits the amount of work that I can do 

Having an amputation limits the kind of work that I can do  Having an amputation limits the kind of work that I can do 

Having an amputation limits the amount of work that I can do  Having an amputation limits the amount of work that I can do 

Having an amputation makes me more dependent on others 
than I would like to be 

 
Having an amputation makes me more dependent on others than 

I would like to be 

My amputation interferes with the ability to do my work  My amputation interferes with the ability to do my work 

 

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6 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 

Parallel analysis indicated a two components solution. One 

item (“I don’t care if somebody looks at my prosthesis”) 

had lower factor loadings for both factors (<0.3) and  

was dropped. This resulted in a two-factor model with 9 

items in each factor (Cronbach’s Alpha = 0.90 and 0.84) 

with acceptable model fit (CFI=0.950, TLI=0.943, 

RMSEA=0.084).  

The RMSEA values for unidimensional model fit for were 

large for factor 1 (CFI=0.963, TLI=0.950, RMSEA=0.105) 

and factor 2 (CFI=0.947, TLI=0.930, RMSEA=0.156). 

Therefore, we further explored unidimensionality by 

confirming that the ratio of the first and second eigenvalues 

was >4. We then stratified the sample by prosthesis users 

(yes vs. no) and repeated the analyses (not shown) to 

confirm that the factor structure was similar for both 

prosthesis users and non-users.  

CFA fit indices for the unstratified model were (CFI=0.934, 

TLI=0.925, RMSEA=0.100). RMSEA for each factor were 

somewhat large (0.138 and 0.193). However, residual 

correlations were <0.2, eigenvalue ratios were >4, and all 

eigenvalues except for the first were <1.0. Thus, we 

concluded that each factor had a unidimensional structure. 

The factors were labeled based on their content as: 1) 

Adjustment to Limitation, and 2) Work and Independence. 

Calibration and DIF analyses 

We used data from the full sample in Rasch partial credit 

models and examined monotonicity of responses and item 

calibrations.  

In the Adjustment to Limitation factor, monotonicity criteria 

were not met for the item “as time goes by, I accept my 

prosthesis more.” To address this, we merged the neutral 

category with the “agree” category for factor scoring. After 

adjustment for this one item, there was no violation of 

monotonicity. In the Work and Independence factor, the 

monotonicity criteria were met for all items. In both factors, 

the neutral response category (“neither disagree nor agree”) 

had a low probability of selection in most items. We explored 

whether adjusting the model to treat selection of the neutral 

category as an extra factor fit the data better. We found that 

the extra factor only affected 6% of respondents, and the 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Flow diagram of item reduction and mapping onto factors. 

 

Two-factor EFA in subsample 1 

18 items 

Adjustment to Limitation: 
 9 items 

Work and Independence:  

9 items 

7 items 

Removed 2 items: 

 DIF and misfitting 

9 items 

Removed 1 item: factor loading<0.3 

19 Items 

Rasch model in combined 

samples 

CFA in subsample 2 

Rasch model in combined 

samples 

CFA in subsample 2 

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Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
adjusted and unadjusted person score correlation was  

near 1. Conceptually, there was no basis to merge this 

neutral category with other categories. Therefore, we kept 

the neutral response category.  

In residual factor analysis, unexplained variance in the first 

contrast was <10% for both factors, and 59.7% and 74.8% 

of the variance was explained by the measures. 

Calibrations for both factors are shown in Table 4. In the 

Adjustment to Limitation factor, two items were dropped due 

to both poor fit and moderate to large DIF by sex: “I have 

difficulty talking about limb loss in conversation” (infit=1.34, 

outfit=1.67, more difficult for men) and “I don’t care if 

somebody looks at my stump” (infit=1.19, outfit=1.56, more 

difficult for women). After dropping these items and re-

analyzing DIF, we observed that two items had slight to 

moderate DIF by sex (“Although I have an artificial limb, my 

life is full”) and laterality (“I find it easy to talk about my 

prosthesis”). In the Work and Independence factor, there 

was slight to moderate DIF by sex (women had more 

difficulty with “having an amputation makes me more 

dependent on others than I would like to be”). There was 

also slight to moderate DIF for three items by laterality 

(those with bilateral amputation had more difficulty).  

Reliability 

Rasch item-person maps for both subscales (Figure 2) 

showed that item difficulties (including the lowest and 

highest categories) sufficiently covered the range of person 

ability scores. Rasch reliability correlation coefficients for 

factor 1 were 0.70 for person reliability and 0.95 for item 

reliability. In factor 2, the person reliability correlation 

coefficient was 0.87 and the item reliability correlation 

coefficient was 0.99. 

Given that non-prosthesis users only completed two items 

in the Adjustment to Limitation subscale, we examined 

reliability of this factor for nonusers and found that person 

reliability was 0.49. However, after removing extreme cases 

(those with highest or lowest responses for every item), the 

person reliability was 0.73. In the Adjustment to Limitation 

subscale, 87% of respondents had scores in the range (22.9 

to 61.6) with a score reliability of 0.8 or higher (Figure 3). In 

the Work and Independence subscale, 96% of respondents 

had scores (29.1 to 70.6) with a reliability at 0.8 or higher 

(Figure 3). 

Cronbach alpha was 0.82 and 0.90 for the Adjustment to 

Limitation and Work and Independence subscales 

respectively, indicating good internal consistency. ICC (type 

3,1) was 0.63 for the Adjustment to Limitation subscale and 

0.80 for the Work and Independence subscale indicating 

moderate and good test-retest reliability, respectively 

(Table 5). MDC 90 and 95 for the Adjustment to Limitation 

subscale were 17.7 and 14.9, respectively. MDC 90 and 95 

for the Work and Independence subscale were 13.0 and 

10.9, respectively. 

DISCUSSION  

Our objective was to create a psychosocial adjustment 

scale for persons with ULA that could be used in research 

and clinical practice for upper prosthesis users and non-

users alike, overcoming a limitation of the TAPES-ULA 

psychosocial adjustment subscale which is targeted to 

prosthesis users only. The strengths of this study include 

the large sample size and a robust sample of women with 

ULA. The measure that we developed could be used as a 

screening tool in clinical practice to identify persons with 

poor psychosocial adjustment who might benefit from 

referral to behavioral health care providers. A copy of the 

final measure is provided in APPENDIX B. 

Given our sample size and characteristics, we were able to 

evaluate the extent of differential item functioning across 

key population categories. We field tested a 19-item set in 

a sample that included 472 prosthetic users and 255 non-

users. The new Psychosocial Adjustment to Amputation 

measure we developed contains two subscales: a 7-item 

Adjustment to Limitation scale and a 9-item Work and 

Independence subscale. The new subscales had sound 

structural validity, good person and item reliability, and 

moderate to good test-retest reliability. No retained items 

had moderate to large DIF by sex, age, prosthesis use, or 

laterality.  

Our work has application for future studies of psychosocial 

adjustment to ULA. Prior studies in this area were limited to 

persons who use a prosthesis.9,16 We provided estimates of 

minimal detectable change (MDC) that can be used when 

interpreting change in scores at an individual level in 

longitudinal studies of psychosocial adjustment.  

While we believe that our tool is useful in its present state, 

further research is needed to enhance reliability of the 

Adjustment to Limitation subscale. This scale contains only 

two items that can be completed by persons who do not use 

a prosthesis and as such has lower reliability for non-users. 

This finding suggests that this subscale should be used 

cautiously for persons who do not use a prosthesis and that 

it may not be appropriate for use at the person level for 

determining change in Adjustment to Limitation in persons 

who do not use a prosthesis. In contrast, the Work and 

Independence subscale contains 5 items that are pertinent 

to persons who do not use a prosthesis and had stronger 

reliability. We recommend that additional items be 

developed and added to the Adjustment to Limitation 

subscale to enhance its reliability.  

Limitations 

Our study has several limitations. First, our study activities 

were conducted in English language only and with persons 

from the United States. Our findings need to be replicated 
with translated versions and with English speaking persons 

from other countries. 

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Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 

 

 

 

 

 

 

Table 4: Partial credit model of Adjustment to Limitation and Work and Independence Subscales (N=727). 

 
Model Infit Outfit 

Measure SE MNSQ ZSTD MNSQ ZSTD 

Factor 1: Adjustment to Limitation       

I have gotten used to wearing a prosthesis                   41.89 0.32 0.86 -1.5 0.86 -1.4 

As time goes by, I accept my prosthesis more                  40.97 0.55 1.12 1.2 1.06 0.5 

Although I have an artificial limb, my life is full               40.65 0.37 1.16 1.6 1.10 1.0 

I have adjusted to having a prosthesis                     40.46 0.37 0.90 -1.0 0.75 -2.6 

I find it easy to talk about my prosthesis                   39.08 0.41 1.19 1.9 1.12 1.2 

I feel that I have dealt successfully with this trauma in my life        37.10 0.32 0.91 -1.1 0.91 -1.1 

I have adjusted to being an amputee                       36.96 0.32 0.92 -1.0 1.32 3.0 

Factor 2: Work and Independence       

Having an amputation limits the kind of work that I can do                      55.36 0.28 1.04 0.7 0.95 -0.6 

Having a prosthesis limits the kind of work that I can do                      54.02 0.34 1.04 0.5 1.08 0.8 

Having an amputation limits the amount of work that I can do                     51.79 0.22 0.84 -3.1 0.82 -2.8 

Having an amputation makes me more dependent on others than I would like to be            50.67 0.22 0.99 -0.1 1.00 0.0 

Having a prosthesis limits the amount of work that I can do                     50.17 0.34 0.88 -1.9 0.90 -1.3 

Having a prosthesis makes me more dependent on others than I would like to be            50.00 0.34 0.97 -0.4 0.96 -0.5 

Being someone with a limb difference means that I can't do what I want to do             49.22 0.22 1.04 0.7 1.20 3.2 

A prosthesis interferes with the ability to do my work                        47.88 0.34 1.14 2.2 1.31 4.0 

My amputation interferes with the ability to do my work                        47.88 0.22 1.09 1.7 1.25 3.9 

 

           

Figure 2: Adjustment to Limitation (top) and Work and Independence (bottom) item-person maps. 
Note: The histogram of the sample score distribution is shown on the left and level of person ability with 50% probability of selecting each category (vs any higher 

category) for each item is shown on the right. 

Adjustment to Limitation 

Work and Independence 

Adjusted Dealt with trauma Talk about 

prosthesis 

Adjusted having 

prosthesis 
Life full Accept 

prosthesis 

Used to wearing 

prosthesis 

Sample 

Frequency 

Sample 

Frequency Amputation 

work 

interference 

Prosthesis 

work 

interference 

Can’t do 

what I 

want 

Prosthesis 

dependence 

Prosthesis 

amount 

work 

Amputation 

dependence 

Amputation 

amount 

work 

Prosthesis 

kind work 

Amputation 

kind work 

T
 s

c
a
le

 
T

 s
c
a
le

 

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Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 

Second, males in our sample were predominantly veterans, 

while the majority of women were non-veterans. Despite 

this difference, we found only minor differential item 

functioning by sex in the Work and Independence Subscale. 

Although we evaluated differential item functioning at the 

item level, this study did not compare overall scale scores 

by sex.  These types of comparisons will need to be 

conducted in future studies. Our findings may be limited to 

older persons, given that the mean age of our sample was 

61, suggesting findings may not be representative of 

younger persons. Additionally, the sample was 

predominately white and non-Hispanic, limiting the 

generalizability to persons from less diverse backgrounds. 

Further research is needed to assess how findings may vary 

by race and ethnicity.   

Another limitation of the study is that all data were collected 

by interviewer administration by telephone. This mode of 

administration was selected to facilitate response rates and 

reduce respondent burden, given that the psychosocial item 

set was administered as part of a larger study of participant-

reported measures, with interviews lasting about 45 

minutes. We acknowledge that respondents did not have 

copies of the measures or response categories. We made 

special efforts to customize the instructions to make 

telephone administration clear and study interviewers were 

carefully trained, professional survey staff members. 

Further research is needed to examine the revised measure 

when administered by paper and pencil or electronically, 

and to compare results by mode of administration.  

We provided estimates of test-retest reliability and 

estimates of MDC values. Our test-retest subsample was 

only 4% female while the overall sample was 20% female. 

Therefore, these data should be considered preliminary and 

limited to men with ULA. 

CONCLUSION 

We developed a new tool to measure psychosocial 

adjustment in persons with ULA and examined its 

measurement properties. The result was a 7-item 

Adjustment to Limitation subscale and a 9-item Work and 

Independence subscale with sound structural validity, good 

reliability, and evidence supporting test-retest reliability. 

Both scales can be used for persons with ULA to assess the 

  Table 5: Psychosocial Adjustment to Amputation Subscale ICCs and MDCs. 

 N Interview 1: Mn (SD) Interview 2: Mn (SD) ICC (95% CI)* MDC 90 MDC 95 

Adjustment to Limitation 50 51.5 (10.7) 52.6 (10.2) 0.63 (0.42, 0.77) 14.9 17.7 

Work and Independence 50 50.6 (10.4) 51.1 (10.4) 0.80 (0.67, 0.88) 10.9 13.0 
 

*CI: confidence interval, ICC: intraclass correlation coefficient, MDC: minimal detectable change. Note: We interpreted reliability with ICC <0.50 considered poor, 

0.50-0.75 moderate, 0.75-.90 good and >0.90 excellent. 
34

 

 

Figure 3: Adjustment to Limitation (top) and Work and Independence (bottom) test information function plots. 

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10 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
important construct of psychosocial adjustment and identify 

persons who might benefit from behavioral health referral 

regardless of whether they use a prosthesis. However, the 

Adjustment to Limitation subscale has marginal reliability in 

the nonuser subgroup.  

ACKNOWLEDGEMENTS 

This work was supported by the United States (U.S.) Department 

of Veterans Affairs, Rehabilitation Research and Development 

Service. The contents do not represent the views of the U.S. 

Department of Veterans Affairs or the United States Government. 

We thank all participants for their involvement and the Department 

of Veterans Affairs for their support, including study staff Eileen 

Small and John Davey. 

DECLARATION OF CONFLICTING 

INTERESTS 

All authors declare that they have no conflict of interests. 

AUTHOR CONTRIBUTION 

Linda J. Resnik:  

Conceptualization, data interpretation, manuscript, writing, project 

administration, funding acquisition.  

 

Pengsheng Ni:  
Statistical methodology, data analysis, visualization and 

interpretation. 

 

Matthew L. Borgia:  
Statistical methodology, data analysis, visualization and 

interpretation, writing and editing. 

 

Melissa A. Clark:  
Study design, survey design, data interpretation, manuscript review 

and revision. 

 

SOURCES OF SUPPORT 

Department of Veterans Affairs Rehabilitation Research and 

Development Service A2936-R and A9264-S. Sponsors had no role 

in study design, collection, analysis, and interpretation of data. 

ETHICAL APPROVAL 

The study was approved by VA Central institutional review board, 

and all participants gave oral informed consent as approved by the 

IRB. 

REFERENCES 

1.McKechnie PS, John A. Anxiety and depression following 

traumatic limb amputation: A systematic review. Injury. 

2014;45(12):1859-66. DOI: 10.1016/j.injury.2014.09.015 

2.Hill A, Niven CA, Knussen C. The role of coping in adjustment to 

phantom limb pain. Pain. 1995;62(1):79-86. DOI: 10.1016/0304-

3959(94)00253-B 

3.Gallagher P, MacLachlan M. Psychological adjustment and 

coping in adults with prosthetic limbs. Behav Med. 1999;25(3):117-

24. DOI: 10.1080/08964289909596741 

4.Livneh H, Antonak RF, Gerhardt J. Psychosocial adaptation to 

amputation: the role of sociodemographic variables, disability-

related factors and coping strategies. Int J Rehabil Res. 

1999;22(1):21-31. DOI:10.1097/00004356-199903000-00003 

5.Desmond DM. Coping, affective distress, and psychosocial 

adjustment among people with traumatic upper limb amputations. 

J Psychosom Res. 2007;62(1):15-21. DOI: 

10.1016/j.jpsychores.2006.07.027 

6.Armstrong TW, Williamson MLC, Elliott TR, Jackson WT, Kearns 

NT, Ryan T. Psychological distress among persons with upper 

extremity limb loss. Br J Health Psychol. 2019;24(4):746-63. DOI: 

10.1111/bjhp.12360 

7.Cheung E, Alvaro R, Colotla VA. Psychological distress in 

workers with traumatic upper or lower limb amputations following 

industrial injuries. Rehabil Psychol. 2003;48(2):109-12. 
DOI:10.1037/0090-5550.48.2.109 

8.Desmond DM, MacLachlan M. Affective distress and amputation-

related pain among older men with long-term, traumatic limb 

amputations. J Pain Symptom Manage. 2006;31(4):362-8. DOI: 

10.1016/j.jpainsymman.2005.08.014 

9.Desteli EE, Imren Y, Erdogan M, Sarisoy G, Cosgun S. 

Comparison of upper limb amputees and lower limb amputees: a 

psychosocial perspective. Eur J Trauma Emerg Surg. 

2014;40(6):735-9. DOI: 10.1007/s00068-014-0418-3 

10.Saradjian A, Thompson AR, Datta D. The experience of men 

using an upper limb prosthesis following amputation: positive 

coping and minimizing feeling different. Disabil Rehabil. 

2008;30(11):871-83. DOI: 10.1080/09638280701427386 

11.Kristjansdottir F, Dahlin LB, Rosberg HE, Carlsson IK. Social 

participation in persons with upper limb amputation receiving an 

esthetic prosthesis. J Hand Ther. 2019. DOI: 

10.1016/j.jht.2019.03.010 

12.Desmond DM, MacLachlan M. Coping strategies as predictors 

of psychosocial adaptation in a sample of elderly veterans with 

acquired lower limb amputations. Soc Sci Med. 2006;62(1):208-16. 
DOI: 10.1016/j.socscimed.2005.05.011 

13.Talbot SG, Carty MJ, Jensen SE, Dumanian GA. Adjustment to 

amputation and interest in upper limb transplantation. SAGE open 

medicine. 2019; 7:2050312119858248. DOI: 10.1177/ 

2050312119858248 

14.Murray CD. The social meanings of prosthesis use. J Health 

Psychol. 2005;10(3):425-41. DOI:10.1177/1359105305051431 

15.Murray C, ed. Amputation, Prosthesis Use, and Phantom Limb 

Pain. University L, editor. Lancaster LA1 4YT, UK: Springer 

Science & Business Media. 2009  

16.Atherton R, Robertson N. Psychological adjustment to lower 

limb amputation amongst prosthesis users. Disabil Rehabil. 

2006;28(19):1201-9. DOI: 10.1080/09638280600551674 

17.Coffey L, Gallagher P, Horgan O, Desmond D, MacLachlan M. 

Psychosocial adjustment to diabetes-related lower limb 

amputation. Diabet Med. 2009;26(10):1063-7. DOI: 10.1111/j. 

1464-5491.2009.02802.x 

18.Resnik L, Ekerholm S, Borgia M, Clark MA. A national study of 

Veterans with major upper limb amputation: Survey methods, 

participants, and summary findings. PLoS One. 

2019;14(3):e0213578. DOI: 10.1371/journal.pone.0213578 

https://doi.org/10.33137/cpoj.v5i1.37873


 

11 

Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
19.Biddiss EA, Chau TT. Upper limb prosthesis use and 

abandonment: a survey of the last 25 years. Prosthet Orthot Int. 

2007;31(3):236-57. DOI: 10.1080/03093640600994581 

20.Gallagher P, Maclachlan M. The Trinity Amputation and 

Prosthesis Experience Scales and quality of life in people with 

lower-limb amputation. Arch Phys Med Rehabil. 2004;85(5):730-6. 

DOI: 10.1016/j.apmr.2003.07.009 

21.Gallagher P, MacLachlan M. Development and psychometric 

evaluation of the Trinity Amputation and Prosthesis Experience 

Scales (TAPES).  Rehabil Psychol. 2000;45(2):130-54. 
DOI:10.1037/0090-5550.45.2.130 

22.Desmond DM, MacLachlan M. Factor structure of the Trinity 

Amputation and Prosthesis Experience Scales (TAPES) with 

individuals with acquired upper limb amputations. Am J Phys Med 

Rehabil. 2005;84(7):506-13. DOI: 10.1097/01.phm.0000166885. 

16180.63 

23.Peterson CH, Peterson NA, Powell KG. Cognitive Interviewing 

for Item Development: Validity Evidence Based on Content and 

Response Processes. Meas Eval Couns Dev. 2017;50(4):217-23. 

DOI: 10.1080/07481756.2017.1339564 

24.Levine RE, Fowler FJ, Jr., Brown JA. Role of cognitive testing in 

the development of the CAHPS Hospital Survey. Health Serv Res. 

2005;40(6 Pt 2):2037-56. DOI: 10.1111/j.1475-6773.2005.00472.x 

25.Irwin DE, Varni JW, Yeatts K, DeWalt DA. Cognitive interviewing 

methodology in the development of a pediatric item bank: a patient 

reported outcomes measurement information system (PROMIS) 

study. Health Qual Life Outcomes. 2009;7:3. DOI: 10.1186/1477-

7525-7-3 

26.Revelle W. Procedures for psychological, psychometric, and 

personality research [Internet]. Evanston, Illinois: Northwestern 

University; 2021 [cited 2021 December 17]. Available from: 

https://CRAN.R-project.org/package=psych 

27.Muthen L, Muthen B. MPlus Statistical analysis with latent 

variables user's guide. Los Angeles, CA: Muthen & Muthen; 2007. 

28.Yen W. Scaling performance assessments: strategies for 

managing local item dependence. J Educ Meas. 1993;30(3):187-

213. DOI: 10.1111/j.1745-3984.1993.tb00423.x 

29.Tate R. A comparison of selected empirical methods for 

assessing the structure of responses to test items. Appl Psychol 

Meas. 2003;27(3):159-203. DOI: 10.1177/0146621603027003001 

30.Chen W, Thissen D. Local dependence indexes for item pairs 

using item response theory.  J Educ Behav Stat. 1997;22:265-89. 

DOI: 10.3102/10769986022003265 

31.Tennant A, Conaghan PG. The Rasch measurement model in 

rheumatology: what is it and why use it? when should it be applied, 

and what should one look for in a Rasch paper? Arthritis Rheum. 

2007;57(8):1358-62. DOI: 10.1002/art.23108  

32.Tennant A, McKenna SP, Hagell P. Application of Rasch 

analysis in the development and application of quality of life 

instruments. Value Health. 2004;7 Suppl 1:S22-6. DOI: 

10.1111/j.1524-4733.2004.7s106.x 

33.Zwick R, Thayer, D.T., Lewis, C. An empirical bayes approach 

to mantel-haenszel DIF analysis. J Educ Meas. 1999;36(1):1-28. 

34.Koo TK, Li MY. A guideline of selecting and reporting intraclass 

correlation coefficients for reliability research. J Chiropr Med. 

2016;15(2):155-63. DOI: 10.1016/j.jcm.2016.02.012 

 

 

 

 

 

 

 

 

 

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Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
APPENDIX A 

Measure Used in Field Testing 
 
 

Thinking about your upper limb amputation, how much do you disagree or agree with each of the following statements? 
 

 

Strongly 
Disagree 

Disagree 
Neither Disagree 

nor Agree 
Agree 

Strongly 
Agree 

DON’T 
KNOW/ 

NOT SURE 
[DO NOT 
READ] 

REFUSED 
[DO NOT 
READ] 

a. I have adjusted to being an 
amputee [Would you say 
Strongly Disagree, Disagree, 
Neither Disagree nor Agree, 
Agree, or Strongly Agree?] 

1 2 3 4 5 98 99 

b. I feel that I have dealt 
successfully with this trauma in 
my life 

1 2 3 4 5 98 99 

c. I don't care if somebody looks at 
my stump 

1 2 3 4 5 98 99 

d. I have difficulty in talking about 
my limb loss in conversation 

1 2 3 4 5 98 99 

e. My amputation interferes with the 
ability to do my work 

1 2 3 4 5 98 99 

f. Having an amputation limits the 
kind of work that I can do 1 2 3 4 5 98 99 

g. Having an amputation limits the 
amount of work that I can do 1 2 3 4 5 98 99 

h. Having an amputation makes me 
more dependent on others than I 
would like to be 

1 2 3 4 5 98 99 

i. Being someone with a limb 
difference means that I can't do 
what I want to do 

1 2 3 4 5 98 99 

 
 
[ASK IF USER]  
Thinking about your prosthesis, how much do you disagree or agree with each of the following statements? 
 

 

Strongly 
Disagree 

Disagree 
Neither Disagree 

nor Agree 
Agree 

Strongly 
Agree 

DON’T 
KNOW/ 

NOT SURE 
[DO NOT 
READ] 

REFUSED [DO 
NOT READ] 

a. I don't care if somebody looks 
at my prosthesis [Would you 
say Strongly Disagree, 
Disagree, Neither Disagree nor 
Agree, Agree, or Strongly 
Agree?]  

1 2 3 4 5 98 99 

b. I have adjusted to having a 
prosthesis 

1 2 3 4 5 98 99 

c. As time goes by, I accept my 
prosthesis more 

1 2 3 4 5 98 99 

d. Although I have an artificial 
limb, my life is full 

1 2 3 4 5 98 99 

e. I have gotten used to wearing a 
prosthesis 

1 2 3 4 5 98 99 

f. I find it easy to talk about my 
prosthesis 

1 2 3 4 5 98 99 

g. A prosthesis interferes with the 
ability to do my work 

1 2 3 4 5 98 99 

h. Having a prosthesis limits the 
kind of work that I can do 

1 2 3 4 5 98 99 

i. Having a prosthesis limits the 
amount of work that I can do 

1 2 3 4 5 98 99 

j. Having a prosthesis makes me 
more dependent on others than 
I would like to be 

1 2 3 4 5 98 99 

 
 

 

 

 

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Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 
2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 

ISSN: 2561-987X PSYCHOSOCIAL ADJUSTMENT AFTER UPPER LIMB AMPUTATION 

Resnik et al., 2022 CPOJ 

 
APPENDIX B 

Subject 
Number 

  Date:// 
            Mon/day/year 

 

Psychosocial Adjustment to Amputation Measure  
 
1.Thinking about your upper limb amputation, please indicate how much you disagree or agree with each of the following statements. 

 

 Strongly Disagree Disagree 
Neither Disagree nor 

Agree 
Agree Strongly Agree 

Adjustment to Limitation      

I have adjusted to being an amputee  1 2 3 4 5 

I feel that I have dealt successfully with 
this trauma in my life 

1 2 3 4 5 

Work and Independence       

My amputation interferes with the 
ability to do my work 

5 4 3 2 1 

Having an amputation limits the kind of 
work that I can do 

5 4 3 2 1 

Having an amputation limits the 
amount of work that I can do 

5 4 3 2 1 

Having an amputation makes me more 
dependent on others than I would like 
to be 

5 4 3 2 1 

Being someone with a limb difference 
means that I can't do what I want to do 

5 4 3 2 1 

 
 
   
2. Thinking about your prosthesis, please indicate how much you disagree or agree with each of the following statements. 
 

 
Strongly 
Disagree 

Disagree 
Neither 

Disagree nor 
Agree 

Agree Strongly Agree 

Adjustment to Limitation      

I have adjusted to having a 
prosthesis 

1 2 3 4 5 

As time goes by, I accept my 
prosthesis more 

1 2 3 3 4 

Although I have an artificial limb, 
my life is full 

1 2 3 4 5 

I have gotten used to wearing a 
prosthesis 

1 2 3 4 5 

I find it easy to talk about my 
prosthesis 

1 2 3 4 5 

Work and Independence       

A prosthesis interferes with the 
ability to do my work 

5 4 3 2 1 

Having a prosthesis limits the kind 
of work that I can do 

5 4 3 2 1 

Having a prosthesis limits the 
amount of work that I can do 

5 4 3 2 1 

Having a prosthesis makes me 
more dependent on others than I 
would like to be 

5 4 3 2 1 

 

 

https://doi.org/10.33137/cpoj.v5i1.37873

