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VOLUME 7, ISSUE 1 

 2024 
 

RESEARCH ARTICLE 

 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones 

for individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890   

 

https://jps.library.utoronto.ca/index.php/cpoj/index
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https://doi.org/10.33137/cpoj.v7i1.43890


 

1 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

 

 

RESEARCH ARTICLE 

 

DETECTING CHANGES IN COMFORT, PAIN, AND MOBILITY OVER CLINICAL MILESTONES 

FOR INDIVIDUALS WITH LOWER LIMB LOSS 

Pousett B.M1,2 *, Harasym C.C3, Rapaport M.S1, Richardson T1, Spellen J1, Moe D.W1, Miller W.C4 

1.Barber Prosthetics Clinic, Vancouver, Canada.  
2.Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada.  
3.Biomechanical Engineering, University of British Columbia, Vancouver, Canada. 
4.G.F. Strong Rehabilitation Research Program & Department of Occupational Science and Therapy, Faculty of Medicine, University of British Columbia, 

Vancouver, Canada. 
 
 
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Prosthetic treatment seeks to achieve a shared goal and 

influence a change in function. Mobility is a primary goal of 

treatment and is supported by a comfortable prosthesis that 

is free of pain.1 The provision of a prosthesis occurs at two 

phases: initial rehabilitation and subsequent replacement 

socket. 

 

 

 

The baseline and end point of each phase are important 

milestones, and progress should be measured at these 

points to determine if a change has occurred and a goal has 

been achieved. Socket comfort, pain and mobility are critical 

indicators of successful prosthetic treatment. However, 

there is little data regarding how these values change at 

different clinical milestones.  

Outcome measures (OMs) are a way to provide evidence of 

change toward a goal.2-4 The 2 Minute Walk Test (2MWT),5 

Prosthetic Limb Users Survey of Mobility (PLUS-M),6 Socket 

Comfort Score (SCS),7 and Pain Scale (PS)8 are four OMs 

that measure critical prosthetic treatment indicators. The 

Canadian Amputations Rehabilitation Evidenced-Based 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Functional mobility, comfort and the absence of pain are key goals of prosthetic treatment. 

Outcome measures (OMs) evaluate the impact of treatment and normative and minimal detectable change (MDC) 

values are key to interpreting these scores and measuring treatment outcomes. 

OBJECTIVES: This study seeks to 1) present practice-based normative values of four commonly used OMs at 

four prosthetic milestones and 2) explore the MDC of the measures over the treatment period.  

METHODOLOGY: A chart review was conducted of OMs collected with individuals with lower limb loss between 

January 1, 2015, and December 31, 2023. This included data for individuals with unilateral transtibial (TT), 

transfemoral (TF) and rotationplasty (RP) amputations and bilateral transtibial amputation (BTT). OMs included 

the Socket Comfort Score (SCS), Pain Scale (PS), 2 Minute Walk Test (2MWT), and Prosthetic Limb Users Survey 

of Mobility (PLUS-M). Data were collected at four milestone time points: (1) Baseline and (2) Discharge from 

Rehabilitation for those in initial prosthetic rehabilitation, and (3) Initial Evaluation and (4) Definitive Delivery for 

those receiving a replacement socket. Normative values and MDC values were calculated. 

FINDINGS: Data from 30 individuals undergoing in-patient rehabilitation and 74 individuals receiving a 

replacement socket were included. Practice-based normative data were different for each level of amputation and 

milestone and had the following ranges: SCS: 5.7 – 9.1, PS: 0.8 – 3.7, 2MWT: 68.4 – 146.3 m and PLUS-M: 38.9 

– 57.3. MDC values also varied based on time in treatment (Rehabilitation: SCS = 2.5, PS = 1.6, 2MWT = 32.6, 

PLUS-M = 8.8; Replacement Socket: SCS = 3.1, PS = 2.6, 2MWT = 38.9, PLUS-M = 4.0). All measures had a 

statistically significant change over the intervention, however, no average scores changed by greater than the 

MDC.  

CONCLUSIONS: The normative data and MDC scores demonstrate the PS & PLUS-M are useful measures of 

pain and mobility at all points within treatment. The 2MWT is indicated for individuals in rehabilitation, while the 

SCS is indicated for those receiving a replacement socket, as both effectively measure treatment goals that are 

particularly important for each phase of rehabilitation. This provides clinicians with practice-based evidence that 

enables them to interpret OM scores, a critical part of the decision-making process along the treatment journey.  

 

 

ARTICLE INFO 

Received: August 22, 2024 

Accepted: October 12, 2024 

Published: October 25, 2024 
 

CITATION 

Pousett B.M, Harasym C.C, 

Rapaport M.S, Richardson T, 

Spellen J, Moe D.W, et al. 

Detecting changes in 

comfort, pain, and mobility 

over clinical milestones for 

individuals with lower limb 

loss. Canadian Prosthetics & 

Orthotics Journal. 2024; 

Volume 7, Issue 1, No.7. 

https://doi.org/10.33137/cpoj

.v7i1.43890 

KEYWORDS 

Prosthesis, Amputation, 

Lower Limb Prosthesis, 

Outcome Measure, Socket 

Comfort, Mobility, Pain, 

Practice-Based Evidence, 

2MWT, Functional Mobility, 

Rehabilitation, PLUS-M 

* CORRESPONDING AUTHOR: 

Brittany Mae Pousett, CP(C), MSc. 

540 SE Marine Dr, Vancouver, BC, Canada, V5X 2T4 

Tel: 604.321.1115. 

E-Mail: brittany@pousett.ca 

ORCID ID: https://orcid.org/0000-0002-2272-7847 

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

Volume 7, Issue 1, Article No.7. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i1.43890
https://doi.org/10.33137/cpoj.v7i1.43890
https://doi.org/10.33137/cpoj.v7i1.43890
mailto:brittany@pousett.ca
https://orcid.org/0000-0002-2272-7847
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

Review Group9,10 and the American Academy of Orthotists 

and Prosthetists11 recommend these measures and their 

constructs as they capture important and relevant 

information and are easy to integrate into the clinic 

environment. However, to be useful, OM scores need to 

have meaning.    

One form of meaning is normative values. Normative  

values, the average values for a population, are dependent 

on population demographics (e.g., age, sex, etc.) and 

pathologies (e.g., cause of amputation) and allow the 

clinician to compare the patient’s outcome with others in the 

population.12 Normative values are often collected in 

research settings, where population characteristics and 

administration methods may differ from clinical 

environments.13 Practice-based normative values provide 

evidence based in clinical practice. Practice-based 

normative values are similar to the clinical population and 

are also recorded in the clinical setting. The Minimal 

Detectable Change (MDC) of a measure is the smallest 

change that falls outside of measurement error.12 This is 

crucial for measuring treatment outcomes as if a patient’s 

OM score has changed by greater than the MDC, it 

indicates that they have experienced a true change.14 

While some OMs have interpretability values from research 

and clinical settings (e.g., the 2MWT),15-17 many studies do 

not specify the timepoint within the treatment pathway and 

cannot show how an OM changes as the individual 

progresses. The relationship between OM scores differs at 

different milestones,18 and we expect that the practice-

based normative values and changes in measures will be 

different at different milestones as well. For example, 

decreased functional mobility is a common consequence of 

lower limb loss19 that rehab programs seek to address. We 

hypothesized those going through initial prosthetic 

rehabilitation may have a larger change in the OMs 

measuring functional mobility, as demonstrated by 

increased distance walked in the 2MWT. Without clinical 

values to give meaning to OM scores and their changes, the 

intended purposes for using OMs cannot be realized.4,13  

Our research objectives were to: A. Present practice-based 

evidence of the normative values of four commonly used 

OMs at four milestones: (1) Baseline and (2) Discharge from 

Rehabilitation for individuals in initial prosthetic 

rehabilitation, and (3) Initial Evaluation and (4) Definitive 

Delivery for those receiving a replacement socket; B. 

Explore which OMs scores changed by more than the MDC 

over the treatment period and may be useful for measuring 

the effectiveness of prosthetic treatment interventions. 

METHODOLOGY 

Study Design & Sample 

A chart review of patients who had OMs data recorded at 

Barber Prosthetics Clinic between January 1, 2015, and 

December 31, 2023, was conducted. The study was 

approved by the Clinical Research Ethics Board at the 

University of British Columbia (H21-02131; H24-00501). To 

be included, patients had to be over the age of 18, have 

unilateral or bilateral amputations above the ankle and 

below the hip, and have OMs data recorded in their chart. 

Patients were excluded if they did not have OMs data for at 

least one OM at Baseline and Discharge from 

Rehabilitation, or Initial Evaluation and Definitive Fitting. 

Data were captured at two clinical milestones for each of the 

two distinct phases of the treatment journey (Figure 1). Initial 

prosthetic rehabilitation is a distinct period from the rest of 

the prosthetic journey due to its large learning component 

and rapid changes in socket fit and mobility. 

 

 

Figure 1: Definitions of the prosthetic milestones included in the 

two distinct phases of the treatment journey. 

Outcome Measures:  

The OMs were administered by Certified Prosthetists who 

had completed computer-based training to use these four 

specific OMs20 as well as in-person feedback to ensure 

consistency in administration. The SCS, PS, PLUS-M and 

2MWT were administered at clinical milestones, regardless 

of treatment goals.  

The 2MWT is a performance-based measure of aerobic 

capacity and functional mobility. It records how many 

meters an individual can walk in 2 minutes. A 10 m hallway 

with in-floor markings was used in most instances but 

walkways of different lengths were used when 10 m 

hallways were unavailable. The variability in hallways length 

is a known issue in the clinic use of the 2MWT.13 Assistive 

devices were used if needed. The 2MWT has published 

normative values based on age, sex, cause of amputation, 

https://doi.org/10.33137/cpoj.v7i1.43890
https://www.barberprosthetics.com/


 

3 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

and level of amputation which makes it easy to interpret to 

the context of the patient.5,15,21-24 It is the only measure that 

has values specified at clinical milestones, as one study 

presented scores at Discharge from Rehabilitation and a 

later follow-up.16 The measure has test-retest reliability for 

individuals with limb loss, ICC = 0.83, and an MDC of 34.4 

m.24 

The PLUS-M is a 12 item self-report mobility survey that 

asks individuals with limb loss to rate their ability to 

complete tasks on a 5-point scale ranging from without any 

difficulty [5] to unable to do [1].25 Clinicians read aloud the 

survey for patient who struggled to complete the test 

independently. The PLUS-M is scored by converting the raw 

scores to a T-score, where a T-score of 50 relates to the 

average score of the original development sample.25 Test-

retest reliability has ICC=0.96, and the MDC-90 of the t-

score of 4.50.26 

The SCS and PS are self-report measures of socket comfort 

and pain intensity, respectively. They are both rated verbally 

on a numerical 11-point scale from 0 (SCS: least 

comfortable socket they can imagine, or PS: no pain) to 10 

(SCS: most comfortable socket they can imagine, and PS: 

worst pain imaginable). The test-retest reliability of the SCS 

is ICC=0.77 and the MDC is 2.82.26  

The PS, while previously used with people with 

amputations27 has little specific interpretability data 

published to date. A study with a combined sample of 

individuals with amputations and spinal cord injuries found 

a change of 1.8 corresponded to a meaningful change in 

pain.27 This measure is similar to the Patient-Reported 

Outcomes Measurement Information System 29-item profile 

(PROMIS-29) Pain Intensity, which asks the identical 

question but has instructions that suggest a different time 

period (7 days vs 24 hours).8,28 The PROMIS-29 Pain 

Intensity has test-retest reliability of ICC = 0.87 and an MDC 

of 1.97. We used the PS due to its clinical prominence, and 

as the PROMIS-29 represents the best available evidence, 

we relied on it to inform our interpretation of the PS.26  

Data Collection: 

OMs data, treatment milestones, and demographic data 

including level of amputation, cause of amputation, time 

since amputation, sex, and date of birth were extracted from 

medical records. If a patient reached a milestone multiple 

times within the included dates (i.e., they had more than one 

replacement socket), the most recent milestone was used. 

Patient charts were included if they had data for at least one 

of the OMs at either Baseline and Discharge from 

Rehabilitation, or Initial Evaluation and Definitive Fitting, so 

that change scores could be calculated.  

Analysis:  

Analysis was done using R Studio (Posit Software, PBC). 

Demographic data were analyzed using descriptive 

statistics and partitioned by level of amputation and phase 

of the treatment journey. Practice-based normative values 

for each measure were partitioned by treatment milestone. 

Mean changes in the OM scores over the paired milestones 

were presented. The mean change values were compared 

to calculated MDC values which were calculated using the 

following formula, using previously established ICC values. 

MDC=1.645* √2* SEM 

SEM=StandardDeviationBaselineScores√(1-ICCtest-retest) 

All MDC values use a 90% confidence interval to be consist 

with what is reported in the literature.24 

The significance of the mean change over treatment was 

calculated using a 95% confidence interval (a = 0.05). A 

beneficial change for the patient would include a positive 

increase in SCS, PLUS-M and 2MWT by greater than the 

MDC, along with a negative change in the PS by more than 

the MDC. 

RESULTS 

Data were collected from 30 individuals going through initial 

prosthetic rehabilitation and 74 individuals getting a 

replacement socket (Table 1). Most individuals in 

rehabilitation were males with transtibial amputations, with 

a mean age of 65.7 years (SD = 12.9). Among those 

receiving a replacement socket, the majority were also 

male, with a mean age of 48.5 years (SD = 16.8), and had 

amputations due to various causes. The subgroup with 

rotationplasty amputations was mostly female, with a mean 

age of 29.3 years (SD = 5.4). 

Practice-Based Normative Values 

Practice-based normative values are presented in Table 2. 

The numbers of individuals included for each measure 

range and some measures are marked as N/A because it is 

not always clinically appropriate to administer every 

measure. For individuals in rehabilitation, males were found 

to have higher SCS and lower PS at Baseline and higher 

PLUS-Ms scores at both Baseline and Discharge from 

Rehabilitation. However, for individuals receiving a 

replacement socket, there is no difference in scores across 

sexes at either milestone. 

Changes in Scores over Treatment Interventions  

Average changes in scores and the percentage of scores 

that changed by more than the MDC are presented in  

Table 3. For individuals in rehabilitation, the PS & 2MWT 

measured change most often, and the SCS measuring 

change the least often. For individuals receiving a 

replacement socket, the PLUS-M measured changes most 

often while the 2MWT rarely did. 

https://doi.org/10.33137/cpoj.v7i1.43890


 

4 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

DISCUSSION 

Through analyzing data from individuals in prosthetic 

rehabilitation or receiving a replacement socket, we were 

able to provide practice-based normative values for four 

commonly used OMs (SCS, PS, 2MWT & PLUS-M) based 

on level of amputation at four distinct clinical milestones. We 

were also able to provide practice-based MDC scores as 

well as demonstrate which measures recorded a change at 

which treatment milestones. This information provides 

clinicians valuable information about interpreting OM scores 

at these clinical milestones. As each outcome measure had 

a different purpose, it is often advantageous to use a variety 

of OMs to measure the changes in distinct aspects of the 

individuals experience (e.g. comfort and functional mobility). 

The practice-based normative values, mean changes in 

scores, and calculated MDC values are different for each 

measure at the different milestones, highlighting the 

importance of interpreting the data within these strata and 

the novelty of this approach. When comparing calculated 

MDC values to those published, the calculated values are 

often smaller for those in rehabilitation and greater for those 

receiving a replacement socket. This value is related to the 

homogeneity of the scores for our specific populations, with 

our population having less variability in OM scores at 

Baseline for those in rehabilitation and more variability in 

OM scores at Initial Evaluation for those receiving a 

replacement socket. 

Table 1: Demographic information of individuals included. 

Individuals with Transtibial Amputations 

 
Receiving Initial Prosthetic 

Rehabilitation (N = 27) 
Receiving a Replacement 

Socket (N = 53) 

Age (years) – Mean (SD)  65.8 (13.6) 49.9 (16.0) 

Male – Number (%) 18 (66.7%) 43 (81.1%) 

Etiology – Number (%) 
Cancer/Tumor 
Congenital 
Injury/Trauma 
Vascular/Diabetes 

     Unknown/Other 

 
1 (3.7%) 
1 (3.7%) 
2 (7.4%) 

22 (81.5%) 
1 (3.7%) 

 
5 (9.4%) 
2 (3.8%) 

23 (43.4%) 
21 (39.6%) 
2 (3.8%) 

Time Since Amputation (years) – Mean (SD) 0.5 (1.0) 9.1 (12.0) 

Time in Rehab (weeks) – Mean (SD)  6.4 (4.5) N/A 

Individuals with Transfemoral Amputations 

 
Receiving Initial Prosthetic 

Rehabilitation (N = 3) 
Receiving a Replacement 

Socket (N = 10) 

Age (years) – Mean (SD)  65.0 (3.6) 51.0 (22.3) 

Male – Number (%) 2 (66.7%) 8 (80.0%) 

Etiology – Number (%) 
Cancer/Tumor 
Congenital 
Injury/Trauma 
Vascular/Diabetes 

 
- 
- 
- 

3 (100.0%) 

 
3 (30.0%) 
1 (10.0%) 
4 (40.0%) 
2 (20.0%) 

Time Since Amputation (years) – Mean (SD)  0.4 (1.0) 22.2 (14.2) 

Time in Rehab (weeks) – Mean (SD)  7.4 (4.2) N/A 

Individuals with Rotationplasty Amputations 

 
Receiving Initial Prosthetic 

Rehabilitation (N = 0) 
Receiving a Replacement 

Socket (N = 4) 

Age (years) – Mean (SD)  - 29.2 (5.3) 

Male – Number (%) - 1 (25.0%) 

Etiology – Number (%) 
Cancer/Tumor 
Congenital 
Unknown 

 
- 
- 
- 

 
1 (25.0%) 
2 (50.0%) 
1 (25.0%) 

Time Since Amputation (years) – Mean (SD) - 20.0 (10.9) 

Individuals with Bilateral Transtibial Amputations 

 
Receiving Initial Prosthetic 

Rehabilitation (N = 0) 
Receiving a Replacement 

Socket (N = 7) 

Age (years) – Mean (SD)  - 45.6 (12.8) 

Male – Number (%) - 5 (71.4%) 

Etiology – Number (%) 
Injury/Trauma 
Vascular/Diabetes 
Unknown 

 
- 
- 
- 

 
2 (28.6%) 
2 (28.6%) 
3 (42.9%) 

Time Since Amputation (years) – Mean (SD)  - 4.0 (3.3) 

 
Note: Time since amputation for those receiving initial prosthetic rehabilitation was the time between the discharge from rehab appointment and their amputation 
date. time since amputation for those receiving a replacement socket was the time between the definitive delivery appointment and their amputation date. 

 

 

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5 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

The demographics were different for the two segments of 

the treatment journey, further highlighting the difference in 

new patients seen in rehabilitation hospitals and 

experienced patients seen in clinics. Those in rehabilitation 

are older and have amputations largely due to vascular 

reasons while those receiving a replacement socket are 

younger and have a wider variety of etiologies of 

amputation.  

SCS 

For individuals in rehabilitation, SCS were high at Baseline 

and remained high at Discharge from Rehabilitation. 

Because the scores remained constant, the average 

change in SCS did not change by the MDC and individuals 

experienced change greater than MDC only 19% of the 

time. This is likely because in this specific clinical 

environment, patients typically see their prosthetist at least 

Table 2: Clinical normative data for outcome measures used in prosthetic treatment. 

 SCS 2MWT (m) PS PLUS-M 

Individuals Receiving Initial Prosthetic Rehabilitation 

Baseline 

Transtibial (N = 24, 20, 17, 26) – Mean (SD) 7.2 (2.3) 68.4 (32.4) 2.7 (1.9) 38.9 (19.4) 

Transfemoral (N = 2, 0, 0, 2) – Mean (SD) 7.5 (0.7) N/A N/A 45.6 (4.0) 

Discharge from Rehabilitation 

Transtibial (N = 24, 20, 17, 26) – Mean (SD) 8.5 (1.0) 107.4 (32.3) 1.0 (1.0) 53.4 (8.4) 

Transfemoral (N = 2, 0 ,0, 2) – Mean (SD) 8.5 (0.7) N/A N/A 43.7 (4.8) 

Individuals Receiving a Replacement Socket 

Initial Evaluation 

Transtibial (N = 56, 50, 48, 56) – Mean (SD) 5.7 (2.9) 126.5 (36.4) 3.7 (3.2) 51.6 (9.1) 

Transfemoral (N = 10, 12, 10, 12) – Mean (SD) 5.8 (2.8) 104.7 (53.8) 3.6 (3.1) 48.2 (6.4) 

Transtibial, Bilateral (N = 8, 6, 5, 8) – Mean (SD) 7.3 (1.6) 132.3 (48.2) 2.5 (1.3) 53.0 (6.6) 

Rotationplasty (N = 3, 3, 2, 4) – Mean (SD) 8.0 (0.0) 100.7 (38.2) 1.5 (0.7) 57.2 (11.0) 

Definitive Fitting 

Transtibial, (N = 56, 50, 48, 56) – Mean (SD) 8.9 (1.2) 132.6 (41.4) 1.4 (1.7) 53.2 (11.4) 

Transfemoral (N = 10, 12, 10, 12) – Mean (SD) 8.0 (2.9) 107.6 (42.2) 3.1 (3.5) 51.2 (9.3) 

Transtibial, Bilateral (N = 8, 6, 5, 8) – Mean (SD) 9.1 (0.8) 146.3 (56.4) 0.8 (1.0) 52.9 (8.0) 

Rotationplasty (N = 3, 3, 2, 4) – Mean (SD) 9.0 (1.0) 112.7 (46.5) 1.5 (0.7) 57.3 (9.7) 

 

Note: The N values are listed as (NSCS, N2MWT, NPS, NPLUS-M) and provide the number of participants included in the SCS, 2MWT, PS and PLUS-M calculations 
respectively.  

 

 Table 3: Average changes in scores for individuals with lower limb loss over prosthetic treatment.  

N 
Change in Score – Mean 

(SD) (m) 
Significance – p-value 

(0.05) 
MDC - 90 

Calculated 
% Changed by MDC 

Calculated 

Individuals Receiving Initial Prosthetic 
Rehabilitation 

 

SCS (N = 26) 1.3 (2.4) 0.013* 2.5 19% 

2MWT (N = 21) 37.9 (30.0) <0.000* 32.6 48% 

PS (N = 18) -1.2 (2.4) 0.053 1.6 50% 

PLUS-M (N = 28) 13.3 (18.3) <0.000* 8.8 43% 

Individuals Receiving a Replacement 
Socket 

SCS (N = 68) 2.9 (2.9) <0.000* 3.1 39% 

2MWT (N = 62) 6.3 (18.6) 0.009* 38.9 6% 

PS (N = 59) -1.9 (2.9) <0.000* 2.6 31% 

PLUS-M (N = 70) 2.3 (5.6) <0.00* 4.0 47% 
 

* Indicates change in score is significant from before to after treatment using a = 0.05.  

 

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6 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

once a week for any adjustments to ensure the socket is 

comfortable. 

Between Initial Evaluation and Definitive Fitting, average 

change in SCS scores were just below the MDC and a 

change greater than the MDC was experienced by 40% of 

individuals. Limb volume changes are a common clinical 

reason for replacement sockets, leading to uncomfortable 

limb-socket interfaces and lower SCS at Initial Evaluation. 

SCS were high when individuals received their definitive 

prostheses, suggesting the goal of providing a comfortable 

interface had been achieved.  

While transtibial and transfemoral prosthesis users reported 

similar levels of comfort at Initial Evaluation, transfemoral 

prosthesis users reported lower levels of comfort at the 

Definitive Fitting. This supports previous research which 

found that individuals with transfemoral amputations 

experience diminished comfort and functional outcomes 

than those with other levels of amputations.29 The nature of 

the intimacy of the socket fit could be a reason transfemoral 

users have less comfortable fitting sockets. In addition, 

individuals using rotationplasty prostheses had high levels 

of comfort at both time points. This is hypothesized to be 

because the deterioration of external prosthetic joints and 

the need for a new socket with new joints is a common 

clinical reason for receiving a replacement socket and does 

not reflect in comfort scores. Previous studies found 

average SCS to be 4.8 before receiving a new socket, 6.8 

twenty minutes after receiving a new diagnostic socket, and 

8.4 for individuals who had been using a well-fitting socket 

for 6 months to 5 years, based on a sample of various lower 

extremity amputation.7 The current sample had higher 

socket comfort scores at all time points, which may be due 

to having fewer transfemoral users, a younger average age, 

and a wider variety of amputation etiologies. 

The SCS is suited for use with patients receiving a 

replacement socket, as it is easy to use, aligns with a 

common treatment goal, and frequently captures the impact 

the intervention has at this milestone. It also can be useful 

for guiding treatment decisions and adding clarity to the 

communication between patients and their prosthetists.18  

For those in rehabilitation, while using the SCS in this 

setting can facilitate clinical conversation, it may not be as 

appropriate for measuring the impact of this intervention. 

PS 

For individuals in rehabilitation, PS scores were low at 

Baseline and remained low at Discharge from 

Rehabilitation, indicating an absence of pain. PS values 

negatively correlate with SCS values as the presence of 

comfort often correlates to the absence of pain.18 While the 

PS does not have previous normative values published, the 

values at Definitive Fitting were lower than the Pain Intensity 

scale from the PROMIS-29 which reported an average 

score of 3.3 for a population that was older, with higher 

levels of amputations and more vascular etiologies30 than 

the current sample. 

For individuals receiving a replacement socket, pain levels 

decreased from Initial Evaluation to Definitive Fitting, 

inversely to SCS, again demonstrating the clinical goal has 

been met in these instances.  

The PS is suitable for use with patients in rehabilitation and 

with patients receiving a replacement socket as it captured 

change over 50% and 31% of the time, respectively. The PS 

is easy to use, aligns with a common treatment goal and 

provides clinicians with helpful information.  

2MWT 

2MWT scores changed notably for the transtibial population 

as individuals progressed through their rehab and were able 

to walk further. 2MWT scores (68.3 m at Baseline in 

Rehabilitation and 107.4 m at Discharge from 

Rehabilitation) were notably higher than previously reported 

patients in rehabilitation (20.4 m for males and 22.5 m for 

females at baseline and 46.0 m for males and 29.1 m for 

females at discharge).16 The current sample had similar 

mean ages and male/female composition, with no 

difference in mean scores based on sex. However, Brooks 

et al. measured the baseline scores earlier in the fitting 

process and had a shorter average time from fitting to 

discharge which may have contributed to the lower scores.  

In addition, individuals with bilateral transtibial limb loss had 

the highest 2MWT scores at Initial Evaluation and Definitive 

Delivery. Previous research has found that individuals with 

unilateral transtibial amputations tend to have higher 2MWT 

scores than those with bilateral transtibial amputations 

during rehabilitation16 and it was hypothesized this 

relationship would exist for replacement sockets as well. 

Perhaps the younger mean age of the individuals with 

bilateral amputations in our study led to their higher 

functional mobility. 

For individuals in rehabilitation, the average change in score 

was larger than the MDC and the 2MWT measured change 

greater than MDC 48% of the time. This demonstrated that 

while this measure is an effective way to document changes 

in functional mobility during initial rehabilitation, pre-

amputation activity and comorbidities, and not just the 

disease or rehabilitation intervention, impact aerobic 

capacity and functional mobility.31  

For individuals receiving a replacement socket, our sample 

also had slightly higher 2MWT scores than most previous 

studies (mean scores 98.8 – 113.2),15,21-23 but less than the 

most recent study (mean score 154.3 m).32 Scores tend to 

be higher in samples with more traumatic and fewer 

vascular amputations, more distal amputation levels, and 

younger populations. Although it was hypothesized that a 

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7 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

new, well-fitting socket would improve walking capacity, this 

was not the case as it only measured a change greater than 

MDC 6% of the time. This demonstrates that straight line 

walking capacity is not affected by this intervention. 

Perhaps a measure including functional tasks could be 

more suited to capture a change in this population. There 

are also personal and environmental considerations such 

as co-morbidities, cardiac function, and confidence that 

determine walking capacity. 

The 2MWT is most useful for individuals in rehabilitation as 

it is easy to administer and measures the impact of 

prosthetic rehabilitation on a patient’s functional mobility, 

which is a primary goal of rehabilitation.1 For individuals 

receiving a replacement socket, the 2MWT is not 

recommended as it does not capture the change that this 

treatment has. 

PLUSM 

For most individuals in rehabilitation, PLUS-M scores were 

below those of the original PLUS-M development sample, 

which is intuitive as they were early in their rehabilitation.25 

PLUS-M Scores at Definitive Fitting were close to the PLUS-

M development sample for individuals with transtibial and 

transfemoral amputations due to trauma, which was the 

most common cause of amputation reported in this 

subgroup of our sample.25 For individuals in rehabilitation, 

the average change in score was larger than the MDC and 

measured a change greater than MDC 43% of the time. For 

individuals receiving a replacement socket, the average 

change in PLUS-M score was below the MDC, but it did 

capture a change greater than MDC 47% of the time, 

demonstrating it is more effective at capturing changes in 

mobility for this population than the 2MWT was.  

The PLUS-M is useful for providing a snapshot of an 

individual’s perceived mobility at a point in time and 

successfully captures the change that prosthetic treatment 

has on an individual at both parts of the treatment journey. 

Perhaps for those whose mobility is the primary goal or 

concern, such as during the aging process, the usefulness 

of this measure would be even greater.  

Limitations 

The data were collected in a single clinical practice. For the 

individuals in the rehabilitation sample, the age, sex, and 

etiology of amputation reflect the incidence of amputation in 

Canada. However, less individuals with transfemoral 

amputations were represented in the current study than the 

incidence rates suggests.33 For those receiving a 

replacement socket, the current sample was younger, had 

less individuals with transfemoral amputations, and had 

more individuals represented with traumatic, cancer or 

congenital amputations.33 But, this helps to ensure that 

demographics reflect other groups at similar milestones.  

It should be noted that individuals in rehabilitation with 

transfemoral limb loss and individuals with rotationplasty 

amputations receiving a new socket had small sample sizes 

and therefore are not representative of that population and 

should be interpreted as such.  

However, it is the first study to our knowledge that provides 

evidence for using OMs with this rotationplasty population 

and has been kept in to provide initial evidence for this 

group. In addition, this is one of the first studies presenting 

information on the Pain Scale for use with people with 

amputations. The practice-based normative values can 

begin to form the evidence on this measure. However, the 

MDC values were calculated using information from the 

PROMIS-29 and should be cautiously interpreted. 

Future work can address the psychometric properties of the 

PS. Finally, since OMs were not selected based on 

treatment goals, they may be measuring constructs that 

were not addressed in treatment. Future work should 

integrate both treatment milestones and treatment goals to 

provide the most accurate assessment of the ability of OMs 

to capture changes due to treatment. 

CONCLUSION 

This study provides clinicians with detailed information on 

how to interpret scores in clinical environments. The impact 

of the treatment was measured before and after each 

intervention using different OMs, thus indicating the need to 

consider treatment milestones when choosing OMs for 

clinical use. Placing more responsibility on the clinician to 

select an OM based on the patient’s goal and milestones 

could provide more meaningful results The development 

and use of outcome measures that capture changes at 

specific treatment milestones and are easy for both patients 

and prosthetists to use are critical for the successful 

implementation of these measures. 

ACKNOWLEDGEMENTS 

We would like to thank the team at Barber Prosthetics Clinic for 

their support in this project, as well as all the patients whose data 

was included in the analysis. 

DECLARATION OF CONFLICTING INTERESTS 

The authors have no conflicts of interest to disclose. 

 

AUTHORS CONTRIBUTION 

• Brittany Mae Pousett: conceptualization, study design, data 

curation, formal analysis, project administration, & writing – 

original draft, review & editing. 

• Charlene C Harasym: study design, data curation, formal 

analysis, & writing – review & editing. 

• Malena Sofia Rapaport: conceptualization, study design, 

investigation & writing – review & editing. 

https://doi.org/10.33137/cpoj.v7i1.43890
https://www.barberprosthetics.com/


 

8 

Pousett B.M, Harasym C.C, Rapaport M.S, Richardson T, Spellen J, Moe D.W, et al. Detecting changes in comfort, pain, and mobility over clinical milestones for 
individuals with lower limb loss. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.7. https://doi.org/10.33137/cpoj.v7i1.43890 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X DETECTING CHANGES IN COMFORT, PAIN AND MOBILITY 

Pousett et al., 2024 

• Tessa Richardson: investigation & writing – review & editing. 

• Jesse Spellen: investigation & writing – review & editing. 

• David W Moe: conceptualization, investigation & writing – 

review & editing.   

• William C Miller: conceptualization, study design, 

investigation, supervision & writing – review & editing. 

SOURCES OF SUPPORT 

Research reported in this article was not supported by any funding 

agency in the public, commercial, or not-for-profit sectors. 

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