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VOLUME 6, ISSUE 1 

 2023 

 

RESEARCH ARTICLE 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 

Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 

https://doi.org/10.33137/cpoj.v6i1.41310 

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https://doi.org/10.33137/cpoj.v6i1.41310


 

1 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 
Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 
https://doi.org/10.33137/cpoj.v6i1.41310 

 

 

RESEARCH ARTICLE 

 

CROSS-CULTURAL ADAPTATION AND VALIDATION OF THE NEPALI VERSION OF THE 

PROSTHETIC LIMB USERS SURVEY OF MOBILITY SHORT-FORM (PLUS-M™/NEPALI-

12SF) IN LOWER LIMB PROSTHESIS USERS 

Bajracharya AR1, Seng-iad S1 *, Sasaki K1, Guerra G2 
 
1 Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand. 
2 Department of Exercise and Sport Science, St. Mary’s University, San Antonio, Texas, 78210, USA. 

  
 

 

 

 

  

 

 

 

 

 

 

 

 
 

INTRODUCTION   

Recent data from the WHO-UNICEF Global Report on 

Assistive Technology (GReAT) estimates that 

approximately 2.5 million people are in need of assistive 

technologies now, and by 2050 that number will rise to 3.5 

million people.1 Moreover, for persons residing in resource 

limited settings, only 3% may have access to vital assistive 

technologies. Several key recommendations have been 

provided in the GReAT report, one of which is to ensure 

effectiveness of assistive technology (AT) and actively 

involve AT users in this process. Lower limb prosthetics are  

 

an essential AT for persons with limb loss disabilities. The 

effectiveness of rehabilitation treatment must be assessed 

using reliable performance based and patient reported 

outcome measures.2 A plethora of instruments have been 

developed to better understand the effect of prosthetic 

treatment on mobility.3–5 The Prosthetic Limb Users Survey 

of Mobility (PLUS-M™) is a recently developed instrument 

for measuring lower limb prosthesis user mobility.6 This 

instrument was developed following rigorous patient 

reported outcome measurement procedures.7 The PLUS-

M™ has good construct validity with Amputee Mobility 

Predictor (AMP)4 and Timed Up and Go test (TUG).8 The 

AMP provides clinicians a tool for determining prosthesis 

user activity level. The Two-Minute Walk Test (2MWT) also 

offers indices of prosthesis user walking capacity in a short 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Objective mobility measurement of Nepali prosthesis users is lacking.  

OBJECTIVE: The objective of this study was to cross-culturally adapt, translate and evaluate construct 

validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M™/Nepali-12 Short Form (SF)) 

instrument in lower limb prosthesis users residing in Nepal. 

 METHODOLOGY: Two forward translations, review and reconciliation, back translation, expert review, 

developer review to create the PLUS-M™/Nepali-12SF. Psychometric testing for internal consistency, 

test-retest reliability and construct validity against the Two-Minute Walk Test (2MWT) and Amputee 

Mobility Predictor with Prosthesis (AMPPRO) were performed on sixty-six lower limb prosthesis users. 

FINDINGS: The majority of populations were with transtibial amputation 45 (68%), with transfemoral 

amputation 15 (23%), with knee disarticulation 5 (7.5%) and with syme’s amputation 1 (1.5%). The most 

common cause of amputation among the population was trauma and the least was tumor. Chronbach’s 

alpha for the PLUS-M™/Nepali-12SF was 0.90, mean T-Score was 52.90, test-retest intraclass 

correlation coefficient (ICC) was 0.94 (95% confidence interval 0.90-0.96). Construct validity with the 

2MWT was good (r = 0.62, p< 0.001) and moderately positive with the AMPPRO (r = 0.57, p< 0.001). 

CONCLUSION: Our research evidenced that the PLUS-M™/Nepali -12SF had excellent reproducibility. 

The significance of this work is that it may allow for the measurement of mobility in austere locations of 

Nepal.  

ARTICLE INFO 

Received: June 27, 2023 

Accepted: August 12, 2023     

Published: August 23, 2023 

CITATION 

Bajracharya AR, Seng-iad S, 

Sasaki K, Guerra G. Cross-cultural 

adaptation and validation of the 

Nepali version of the Prosthetic 

Limb Users Survey of Mobility 

Short-Form (PLUS-M™/Nepali-

12SF) in lower limb prosthesis 

users. Canadian Prosthetics & 

Orthotics Journal. 2023; Volume 6, 

Issue 1, No.1. 

https://doi.org/10.33137/cpoj.v6i1.4

1310 

KEYWORDS 

Prosthetics, PLUS-M, 2MWT, 

Outcome Measurement, Survey, 

Mobility, Nepali, Lower Limb 

Prosthesis. 

 

* CORRESPONDING AUTHOR: 

Sirirat-Seng-iad,  
Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine, Siriraj 
Hospital, Mahidol University, Bangkok, Thailand. 

Email: sirirat.sen@mahidol.edu 

ORCID ID: https://orcid.org/0009-0008-7187-3593 

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

Volume 6, Issue 1, Article No.1. 2023 

 

 

https://doi.org/10.33137/cpoj.v6i1.41310
https://doi.org/10.33137/cpoj.v6i1.41310
https://doi.org/10.33137/cpoj.v6i1.41310
mailto:sirirat.sen@mahidol.edu
https://orcid.org/0009-0008-7187-3593
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 
Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 
https://doi.org/10.33137/cpoj.v6i1.41310 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X PLUS-M™/NEPALI-12SF 
Bajracharya et al., 2023 

and simple to administer assessment.9 These two 

assessments combined offer a practical means for gauging 

mobility in lower limb prosthesis users.10,11 In the event that 

a performance based mobility measurement cannot take 

place, the PLUS-M™ may serve well. Correlation between 

PLUS-M™ and mobility measures has previously indicated 

convergent construct validity.6   

Understanding how well a prosthesis user can walk over the 

varied and sloped terrain in Nepal is important for the Nepali 

prosthetists. Nepali prosthesis users must ambulate in 

these harsh terrains for work, activities of daily living and 

leisure.12 Although the PLUS-M™ is available in many 

languages,13,14 it has yet to be translated and culturally 

adapted to Nepali. The objective of this study was to cross-

culturally adapt, translate and evaluate construct validity of 

the PLUS-M™/Nepali-12 Short Form (SF) instrument in 

lower limb prosthesis users residing in Nepal. 

METHODOLOGY 

Setting 

This study was approved by Siriraj Institutional Review 

Board and also by Nepal Health Research Council. All 

participants provided written informed consent prior to data 

collection. Sixty-six lower limb prosthetic user’s age 18 

who were independent and had received their prosthesis for 

at least six months were purposively selected from regional 

centers. These users had no neurological, musculoskeletal 

or pathologies which would have affected study 

participation. Participants unable to understand Nepali; 

users needing assistance of helper to walk, cognition 

problem, users with underlying medical conditions affecting 

mobility and <18 years of age were excluded from this 

study.  

Cross-cultural translation  

Permission to proceed with translation was received from 

the instrument developer and a formal translation method 

was performed. The developers provided pertinent scoring 

and definition guides for instrument items. Two bilingual 

Nepal and English persons (physical therapist, prosthetist) 

independently established a Nepali version. Next, bilingual 

experts (medical doctor, physical therapist) reviewed 

possible discrepancies. Thereafter, a reconciled version 

was created and back translated by an American who 

speaks Nepali. This backward translation was sent to the 

developer; Professor Brian Hafner to review and 

incorporate or change if needed. The comments and 

suggestions from developer were incorporated in Nepali 

version by translator and revised back translation was again 

sent to the developer for additional feedback. The 

comments and suggestion were collected and incorporated 

in revised back translation and this version was provided to 

three independent bilingual experts (medical doctor, 

physical and occupational therapist). This revised addition 

was modified for precision before being sent to the 

developer for a final review.   

The final PLUS-M™/Nepali 44 - items bank was pre-tested 

by cognitive interview with 7 participants with lower limb 

amputation, which helped to detect respondent 

interpretation. Concurrent probing took place in an interview 

by comparing each item with the help of a manual of 

definitions of terms and intentions of each question item 

provided by the developer.   

Psychometric evaluation  

Demographic data, amputation date, level and etiology 

were recorded. The data collector evaluated performance-

based outcome measures Two-Minute Walk Test (2MWT)15 

and Amputee Mobility Predictor with Prosthesis (AMPPRO), 

and PLUS-M™ Nepali 12 item short form (PLUS-M™/ 

Nepali-12SF). The participants were given the option of 

performing the PLUS-M™ Nepali-12SF first, followed by the 

2MWT, and AMPPRO, or the 2MWT, and AMPPRO 

followed by the PLUS-M™/Nepali-12SF. The 2MWT and 

AMPPRO served as a basis for construct validity testing. In 

the 2MWT participants were instructed to walk as fast as 

possible without running along a flat rectangular outdoor 

walkway of 20 meter (65.6 ft.), and distance was recorded 

in meters. To explore test-retest reliability participants 

performed the PLUS-M™/Nepali-12SF once more two 

weeks later.   

Data analysis 

SPSS v16 (IBM, Armonk, New York, USA) was used to 

analyze data. Characteristics of the participants were 

analyzed using a Pearson Chi Square test (p<0.05) and 

95% confidence interval. Internal consistency was 

assessed via Chronbach’s alpha, with  0.07 considered 

good internal consistency.16 An intra-class correlation 

coefficient (ICC) was employed to evaluate test-retest 

reliability. Construct validity was evaluated using a Pearson 

Correlation Coefficient, with r  0.6 = good to excellent and 

r < 0.6 = poor to moderate correlation.17 

RESULTS 

Sixty-six prosthesis users completed the study (37.26  

11.81 years old) (Figure 1).  

Figure 2 provided item and mean responses to the 

instrument. The overall Chronbach’s alpha for the PLUS-

M™/Nepali-12SF was 0.90 showing good internal 

consistency. This instrument scores using a T-Score which 

is a standardized score with a mean of 50 and standard 

deviation of 10. A higher T-Score is equal to a higher 

mobility and vice-versa. PLUS-M™/Nepali-12SF initial 

mean T-Score was 52.90, with standard deviation 5.6. The 

minimum score was 36.4 and maximum was 67.1.  

https://doi.org/10.33137/cpoj.v6i1.41310


 

3 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 
Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 
https://doi.org/10.33137/cpoj.v6i1.41310 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X PLUS-M™/NEPALI-12SF 
Bajracharya et al., 2023 

Good test-retest ICC for T-Score was seen 0.94 (95% 

confidence interval 0.90-0.96), with initial T-Score being 

52.90  5.6 and retest T-Score being 52.47  5.6 (Figure 3 

and Figure 4).18 Mean distance covered on the 2MWT was 

145.45  34.2m and mean AMPPRO score was 40.18  3.8 

(K3). Construct validity with the 2MWT was good (r = 0.62, 

p< 0.001) and moderately positive with the AMPPRO (r = 

0.57, p< 0.001) (Figure 5).  

 

 

Figure 1: Demographics of study participants (n=66). 

 

 

 

 

Figure 2: Mean participant response on PLUS-M™/Nepali-12SF. 

Note: Figure illustrates mean response on items of the instrument. Lower 

number indicates more difficulty performing the task. Solid large circle is 

mean, smaller circles are individual data points. Solid lines connect tests and 

rain cloud plots on the right indicate data distribution. 

 

Figure 3: Mean test and retest T-Scores for PLUS-M™/Nepali-

12SF 

 

 

Figure 4: Bland-Altman plot of PLUS-M™/Nepali-12SF. Note: 

Average of test and retest (x-axis) plotted against difference between test 

and retest (y-axis). Limits of agreement are represented as dotted lines.  

0 1 2 3 4 5

Are you able to walk a short distance in your home? 
Are you able to step up and down curbs? 
Are you able to walk across a parking lot?

Are you able to walk over gravel surfaces? 
Are you able to move a chair from one room to another?

Are you able to walk while carrying a shopping basket in one hand?
Are you able to keep walking when people bump into you? 

Are you able to walk on a unlit street or sidewalk?
Are you able to keep up with others when walking? 

Are you able to walk across as slipper floor? 
Are you able to walk down a steep gravel driveway? 

Are you able to hike about 2 miles on uneven surfaces including hills? 

4.86

4.42

4.20

3.85

4.68

4.50

3.85

3.70

3.62

2.94

3.35

2.70

<25 (16.7%)

25-35 (31.8%)

36-45 (27.3%)

46-55 (16.8%)

56-65 (7.4%)

Age

Trauma (66.7%)

Infection (12.1%)

Dysvascular (13.6%)

Tumor (7.6%)

Cause

Right TT (33.3%)

Left TT (34.8%)

Right TF (10.6%)

Left TF (12.1%)

Right KD (4.5%)

Left KD (2%)

Symes (1%)

Level

Hilly (72.7%)

Moutainous (6.1%)
Terai (21.2%)Location

<25 (16.7%)

25-35 (31.8%)

36-45 (27.3%)

46-55 (16.8%)

56-65 (7.4%)

Age

Trauma (66.7%)

Infection (12.1%)

Dysvascular (13.6%)

Tumor (7.6%)

Cause

Right TT (33.3%)

Left TT (34.8%)

Right TF (10.6%)

Left TF (12.1%)

Right KD (4.5%)

Left KD (2%)

Symes (1%)

Level

Hilly (72.7%)

Moutainous (6.1%)
Terai (21.2%)Location

30 40 50 60 70

-5

0

5

10

15

Average of the two measures 

D
if

fe
re

n
c
e
 o

f 
th

e
 t

w
o

 m
e
a
s
u

re
s

T
-S

c
o

re
 

PLUS-M™/Nepali-12SF 

https://doi.org/10.33137/cpoj.v6i1.41310


 

4 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 
Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 
https://doi.org/10.33137/cpoj.v6i1.41310 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X PLUS-M™/NEPALI-12SF 
Bajracharya et al., 2023 

 

 

Figure 5: Correlation between PLUS-M™/Nepali-12SF and 

reference mobility measures. Note: A: PLUS-M™/Nepali-12SF to 2MWT; 

B: PLUS-M™/Nepali-12SF to AMPPRO.  

DISCUSSION 

The objective of this study was to cross-culturally adapt, 

translate and evaluate the construct validity of the PLUS-

M™/Nepali-12 SF in lower limb prosthesis users residing in 

Nepal. 

Cross-cultural and linguistic translation achieved high 

internal consistency and T-scores of this study were similar 

to those seen in the developmental PLUS-M™ study, 52.90 

compared to 50.6 Our participants still fell within 1 standard 

deviation of average mobility of over 1,000 lower limb 

prosthesis users.19 Still, our T-Scores were lower than that 

seen in the French speaking population 56.1.13 Regardless, 

T-Scores indicated that our sample were highly capable of 

ambulation in their respective environments. Our test-retest 

findings were excellent and similar to that seen in both the 

French and original developmental study. Good construct 

validity was seen with the 2MWT. The 2MWT was an 

appropriate choice for comparison to the PLUS-M™ as it 

asks the user to walk at their maximum mobility potential.20 

Correlation with the AMPPRO was r = 0.57 and compared 

favorably with that of the original study r = 0.54.  

Participant performance in our study evidenced a high 

mobility and activity level as demonstrated by the AMPPRO, 

2MWT and PLUS-M™/Nepali-12SF scores. This may be a 

result of the younger age, trauma amputation, or trans-tibial 

level of amputation. As trans-tibial prosthesis users 

generally have greater mobility and reduced energy 

expenditure than higher level amputees.21,22 PLUS-M™ 

scores for dysvascular amputees has been reported as 45.3 

 2.4 which is much lower than our sample but still within 1 

standard deviation of mobility of lower limb prosthesis 

users.  

Our participants walked on average 145m during the 2MWT 

which is much lower than able-bodied persons (183-

200m),23 but very similar to that of trans-tibial users (147.02 

± 25.9).24 Distances covered are a reflection of walking 

speed, which in our study was 72.5 m/min. Others have 

observed speeds of 82.3 m/min for trans-tibial and 61.7 

m/min for transfemoral users during the 2MWT.25 The 

Amputee Mobility Predictor (AMP) is a popular outcome 

measure that many clinicians use to categorize amputee 

activity potential.26 K-Level Classification is a commonly 

used system to classify the functional level of persons with 

lower limb amputation based on their mobility and ability for 

potential prosthetic use. The K-Level Classification System 

indicates a level of functional ability and mobility which 

commonly ranges from K0- non ambulatory to K4- highly 

active. In the present study, we saw most of our participants 

being categorized as K3 level ambulators. Although in the 

United States, K-level greatly influences prosthetic 

prescription and resources, it plays little precedent in Nepali 

health policy.  

Limitations 

This study is not without its limitations. Although we 

recruited a large sample of lower limb amputees, most lost 

their limbs as a result of trauma which is not a generalization 

of typical amputation causes. There are reports that nearly 

93.4% of amputations are caused by dysvascular 

reasons.27 Moreover, Nepal experienced a major 

earthquake in the last decade and road traffic trauma is one 

startling cause of amputation in the region.28 Taken 

together, these two factors may have influenced the sample 

we relied on for this study. Although it may seem useful to 

use the PLUS-M™ as a prosthetic outcome measure for 

new patients, it is recommended to prolong administration 

until users are accommodated. However, recent 

scholarship has revealed no worsening or improvement in 

PLUS-M™ scores from 1 to 7 year.29 

CONCLUSION 

In this study, we performed cultural contextual translation of 

a widely used prosthetic mobility outcome measure. Our 

research evidenced that the PLUS-M™/Nepali-12SF that 

30 40 50 60 70

0

50

100

150

200

250

PLUS-M/Nepali-12SF 

2
M

W
T

r = 0.62

A

30 40 50 60 70

0

10

20

30

40

50

PLUS-M/Nepali-12SF 

A
M

P
ro

r = 0.57

B

30 40 50 60 70

0

50

100

150

200

250

PLUS-M/Nepali-12SF 

2
M

W
T

r = 0.62

A

30 40 50 60 70

0

10

20

30

40

50

PLUS-M/Nepali-12SF 

A
M

P
ro

r = 0.57

B

PLUS-M™/Nepali-12SF 

PLUS-M™/Nepali-12SF 

A
M

P
P

R
O

 

https://doi.org/10.33137/cpoj.v6i1.41310


 

5 

Bajracharya AR, Seng-iad S, Sasaki K, Guerra G. Cross-cultural adaptation and validation of the Nepali version of the Prosthetic Limb Users Survey of Mobility 
Short-Form (PLUS-M™/Nepali-12SF) in lower limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.1. 
https://doi.org/10.33137/cpoj.v6i1.41310 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X PLUS-M™/NEPALI-12SF 
Bajracharya et al., 2023 

had excellent reproducibility, meeting standards set forth by 

the instrument developer for individual comparisons. The 

significance of this work is that it may allow for the 

measurement of mobility in austere locations of Nepal. 

Furthermore, the instrument can be added to performance-

based outcome measures to create a broader battery of 

outcome measures used to understand a prosthesis user’s 

mobility.  

The PLUS-M™/Nepali-12SF is currently available for use 

on the PLUS-M™ website for download and use by 

clinicians (https://plus-m.org/translations.html). It is hoped that 

clinicians residing in Nepal can begin to monitor lower limb 

prosthesis user mobility in an objective, reliable way and 

simple manner.   

ACKNOWLEDGEMENTS 

The authors would like to acknowledge the participants and 

partnering clinics for their support with this research. This research 

was supported by the Graduate Scholarship for International 

Students from Neighbouring Countries, Faculty of Medicine Siriraj 

Hospital, Mahidol University. 

DECLARATION OF CONFLICTING INTERESTS 

The authors declare no conflicts of commercial or financial interest 

in this research. 

AUTHORS CONTRIBUTION 

Amit Ratna Bajracharya: writing (original drafting) 

Sirirat Seng-iad, Kazuhiko Sasaki, and Gary Guerra: 

conceptualization, writing. 

All authors have read and agreed to this published version of the 

manuscript. 

SOURCES OF SUPPORT 

This research received no financial support. 

ETHICAL APPROVAL 

This study was approved by Siriraj Institutional Review Board and 

also by Nepal Health Research Council. All participants provided 

written informed consent prior to data collection. 

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