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VOLUME 5, ISSUE 1 

 2022 

 

RESEARCH ARTICLE 

Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb 

amputations. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

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1 

Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

 

 

 
RESEARCH ARTICLE 

 

ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY IN THOSE WITH 

NEW LOWER LIMB AMPUTATIONS 

Frengopoulos C 1*, Zia Z 2, Payne M.W.C 3, 4, Viana R 3, 4, Hunter S.W 1,4, 5 
 
1 Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada. 
2 Michael G. DeGroote School of Medicine, McMaster University, London, Ontario, Canada. 
3 Department of Physical Medicine & Rehabilitation, Parkwood Institute, London, Ontario, Canada. 
4 Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. 
5 School of Physical Therapy, University of Western Ontario, London, Ontario, Canada. 

  
 

 

 

 

  

 

 

 

 

 

 

 

 
 

 

 

INTRODUCTION   

Individuals encounter significant physical, psychological 

and social consequences following the loss of a limb.1 While 

the physical concerns of decreased mobility are paramount,   

there are also difficulties with community participation  and 

 

 

 

 

body image that requires attention.2 Rehabilitation for lower 

limb amputation (LLA) is multidisciplinary and goals include 

restoring independent mobility and enhancing quality of life 

(QOL).3 Performance on objective measures of mobility is 

often considered to be the gold standard for evaluating 

rehabilitation progress or success.4 However, subjective 

assessments can also be considered as they may provide 

insight for perceived mobility in scenarios not tested in 

clinical environment. There is an established trend in 

 
OPEN  ACCESS Volume 5, Issue 1, Article No.4. 2022 

 

 

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

 

ABSTRACT 

BACKGROUND: A relationship between walking ability and self-efficacy has been demonstrated in 

various rehabilitation patient populations. In experienced prosthetic ambulators, walking ability is related 

to self-efficacy of balance, however, this relationship has not been quantified for those with newly 

acquired lower limb amputations (LLA). 

OBJECTIVE(S): To investigate the association between walking performance (objective) and self-

reported walking abilities (subjective) on balance self-efficacy in those with LLA. 

METHODOLOGY: Cross-sectional study of 27 people (17 men; mean age=63.57±9.33) at discharge 

from inpatient prosthetic rehabilitation for first major unilateral LLA. Individuals completed 6m straight 

path walking and the L-Test under single- and dual-task conditions. The Prosthesis Evaluation 

Questionnaire (PEQ) was administered, and the Ambulation subscale provided subjective measures of 

walking ability. A single PEQ question on satisfaction with walking (16B) was also used as a proxy for 

subjective walking ability. The Activities-specific Balance Confidence Scale measured balance self-

efficacy. Multivariable linear regression was used to evaluate the strength of association between 

walking ability (objective and subjective) and balance self-efficacy (dependent variable).  

FINDINGS: Walking velocity on the 6m straight path under single-task (p=0.011) and dual-task 

conditions (p=0.039), the single-task L-Test (p=0.035) and self-reported satisfaction with walking 

(p=0.019) were associated with self-efficacy of balance. 

CONCLUSION: Objective measures of walking ability that were independently associated with balance 

self-efficacy included straight path walking velocity under single and dual-task conditions and the single-

task L-Test. Satisfaction with walking was also associated with balance self-efficacy. This highlights the 

interplay between physical and psychological factors during rehabilitation. More research in the area of 

self-efficacy and walking ability is needed to establish self-efficacy as a target during prosthetic 

rehabilitation for those with LLA.  

ARTICLE INFO 

Received: August 8, 2021 

Accepted: January 2, 2022 

Published: January 11, 2022 

CITATION 

Frengopoulos C, Zia Z, Payne 

M.W.C, Viana R, Hunter S.W. 

Association between balance self-

efficacy and walking ability in those 

with new lower limb amputations. 

Canadian Prosthetics & Orthotics 

Journal. 2022; Volume 5, Issue 1, 

No.4. 

https://doi.org/10.33137/cpoj.v5i1.3

6695 

KEYWORDS 

Amputation, Self-Efficacy, Balance 

Confidence, Walking Ability, 

Rehabilitation, PEQ 

 

* CORRESPONDING AUTHOR 

Courtney Frengopoulos, 
University of Western Ontario, Room 1408, Elborn College, London, 
Ontario, Canada, N6G 1H1. 

Email: cfrengop@uwo.ca 

ORCID ID: https://orcid.org/0000-0002-4131-2727 

https://doi.org/10.33137/cpoj.v5i1.36695
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v5i1.36695
https://doi.org/10.33137/cpoj.v5i1.36695
mailto:cfrengop@uwo.ca
https://orcid.org/0000-0002-4131-2727


 

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Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY  

Frengopoulos et al., 2022 CPOJ 

 
walking ability following prosthetic rehabilitation for LLA; the 

largest improvements in self-reported functional mobility 

occur between 6 weeks and 4 months post-surgery, after 

which time function plateaus.5  

While mobility and function improve during rehabilitation, 

the LLA population may experience difficulties with gait that 

persist long-term.6,7 Falls are a particular concern in this 

population, as over half of those with LLA fall at least once 

annually.8,9 After a fall, older individuals without LLA may 

limit their walking due to impact on self-efficacy and a fear 

of falling.9 However, walking is crucial for social participation 

and maintaining QOL in those with LLA.10 As such, the 

impact of psychological factors on walking ability in this 

population have been investigated. Research indicates that 

factors such as self-efficacy may impact upon the 

rehabilitation goals of social activity and community 

integration for those with LLA.11,12  

Self-efficacy is an individual’s belief in their ability to perform 

a certain task.13 Developing self-efficacy may be done 

through observing successful peers or through verbal 

persuasion from credible individuals, such as 

physicians.13,14 However, the strongest sources of self-

efficacy are mastery experiences; other sources are 

generally weak and are likely to deteriorate.14,15 Mastery 

experiences are the successful completion of a specific 

task.15 These experiences can build upon each other as an 

individual accomplishes progressively more difficult 

activities.15 As such, the mastery experience of ambulating 

with a prosthetic device would be expected to strongly 

impact a person’s sense of competence and self-efficacy.  

Research has demonstrated a positive relationship between 

walking performance and self-efficacy following a stroke,16 

in those with knee osteoarthritis,17,18 for those with diabetes 

and peripheral arterial disease,19 and in individuals with 

multiple sclerosis.20 However, the experience following LLA 

is different to these populations as the latter have previous 

mastery experiences from which they derive their self-

efficacy. At the onset of rehabilitation, all tasks relating to 

the prosthetic device are novel. Prosthetic training provides 

a series of mastery experiences for new skills related to the 

use of a prosthesis, allowing those with LLA to develop self-

efficacy. Individuals also receive encouragement from 

clinicians during their time in prosthetic rehabilitation and 

are able to observe fellow patients. Levels of self-efficacy 

during this rehabilitation process have not been reported, 

however, for more experienced prosthetic ambulators, 

walking ability is related to balance self-efficacy.12 

Physical and psychological factors are both important 

considerations for rehabilitation following LLA. For the 

psychological factor of self-efficacy to be addressed as a 

target during the rehabilitation process, a better 

understanding of the relationship between walking ability 

and self-efficacy is needed. To quantify the relationship 

between self-efficacy of balance and walking ability in those 

with LLA, self-reported measures of ability and objective 

walking performance must be carried out. The objective of 

this study was to investigate the association between 

walking performance (objective) and self-reported walking 

ability (subjective) on balance self-efficacy in those with LLA 

at discharge from inpatient prosthetic rehabilitation. It is 

hypothesized that at this stage in the rehabilitation process 

straight path walking and complex path walking under 

single-task conditions, as well as patient satisfaction with 

walking, will be related to balance self-efficacy.  

METHODOLOGY 

Design and Participants 

This was a cross-sectional study of individuals completing 

inpatient prosthetic rehabilitation for first major LLA. 

Participants were recruited from the Regional Amputee 

Rehabilitation Program at Parkwood Institute in London, 

Ontario between March 2016 and April 2017. The study was 

approved by the University of Western Ontario Ethics 

Board, and by the Lawson Health Research Institute Clinical 

Resources Impact Committee. All individuals provided 

written informed consent prior to participating in the study. 

Individuals participating in an inpatient rehabilitation 

program for their first major, unilateral LLA were recruited 

prior to discharge. LLA at the level of transtibial or above 

were considered major amputations; these were selected 

as the represent the most common levels seen in prosthetic 

rehabilitation programs. All individuals were new prosthetic 

ambulators as they were fitted with a prosthesis upon 

commencement of inpatient rehabilitation. Admission 

criteria to inpatient rehabilitation include achievable 

rehabilitation and prosthetic goals, medically stable and 

sufficiently conditioned to undergo a training program, 

ability to learn and retain new skills, and emotionally and 

socially (housing, funding, outside responsibilities, etc.) 

prepared to participate. Training involved prosthetic limb 

fitting, limb care and management, and safe skill learning to 

progress from transfers to gait training with the use of 

various gait aids. Eligibility criteria for the current study 

were: ≥50 years of age, functional use of English and ability 

to walk 10m without assistance from another person. 

Exclusion criteria included any physical problem that 

significantly limited movement or presence of severe 

depression. Those were severe depression were excluded 

as depression can negatively impact performance on 

cognitive tasks requiring attention and visuospatial abilities, 

especially in older adults.21 A total of 27 participants were 

recruited during the study period.  

The following demographic and medical history information 

was obtained: age, sex, height, weight, level of amputation, 

etiology of amputation, time since amputation, use of 

walking aid at discharge, level of education, medications, 

https://doi.org/10.33137/cpoj.v5i1.36695


 

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Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY  

Frengopoulos et al., 2022 CPOJ 

 
comorbidities, history of falls in the past 12 months, global 

cognitive status as measured by the Montreal Cognitive 

Assessment (MoCA). 

Objective Measures of Walking Ability  

The L-Test is a complex walking task that evaluates 

functional mobility for those with LLA.22 Testing was carried 

out under single- and dual-task conditions with standardized 

instructions.22,23 Using standard instructions, participants 

began sitting on an armless chair and upon the word “go” 

rose to standing and walked 3 meters, turned 90 degrees, 

walked 7 meters, turned 180 degrees, and walked the same 

path to return to a seated position. Patients walked at their 

usual pace and were timed to the nearest 100th of a second.  

A 6m straight path assessed gait velocity (cm/s) under 

single- and dual-task conditions. Participants walked at their 

usual pace along the GAITRite® System electronic walkway 

(CIR Systems, Franklin, NJ). One-meter acceleration and 

deceleration zones were provided to ensure only steady 

state walking was captured. Assessment of gait velocity 

using the GAITRite® System was performed separately to 

the walking assessment using the L-Test.  

Subjective Measures of Walking Ability  

The Prosthesis Evaluation Questionnaire (PEQ) is a self-

administered tool that evaluates prosthetic related QOL.24 It 

consists of 9 stand-alone subscales including Ambulation, 

Appearance, Frustration, Perceived Response, Residual 

Limb Health, Social Burden, Sounds, Utility and Well Being. 

The Ambulation subscale was used to assess self-

perceived walking ability (questions 13A, 13B, 13C, 13D, 

14E, 14F, 14G, 14H).24 The following standalone question 

relating to participant satisfaction (question 16B) was also 

used: “Over the past four weeks, rate how satisfied you 

have been with how you are walking”. Questions utilize a 

100mm Visual Analog Scale (VAS) from “cannot” (0) to “no 

problem” (100). Higher scores indicate a more positive 

response.24 The complete PEQ was administered to 

participants. 

Measure of Balance Self-Efficacy  

The ABC Scale is a 16-item tool that evaluates balance 

confidence, or self-efficacy of balance.25 Participants rate 

how confident they are in performing activities without losing 

their balance or becoming unsteady, from 0% to 100%. A 

mean of the 16 items gives the overall score, with higher 

scores indicating better balance self-efficacy.25 The scale 

has good test-retest reliability and internal consistency in 

the LLA population.26  

Testing Protocol 

Single-task (walking test alone) and dual-task (walking task 

paired with cognitively demanding task) walking 

assessments were performed in this study. Demographic 

and clinical information was collected first. Following this, 

walking tasks were demonstrated by a research assistant. 

Participants then completed single-task assessments and 

received a 5-minute break before completing dual-task 

testing. Only one trial per walking test was completed. Dual-

task testing using a cognitively demanding task was used to 

more closely approximate real-world walking.27 The task 

chosen to represent this increased cognitive load was serial 

subtraction by 3’s, starting from a randomly selected 

number between 100 and 150. Participants were instructed 

to count aloud as they walked, and responses were 

recorded. No instructions on task prioritization were given. 

All assessments occurred within 48 hours of discharge. 

Patients used their usual gait aids to perform walking tests. 

A standardized protocol, based on Hunter et al.,23 was used 

during testing. 

Statistical Analysis  

Variables were calculated as means and SDs or 

frequencies and percentages, as appropriate. Multivariable 

linear regression was used to evaluate the strength of 

association between walking ability (objective and 

subjective) and balance self-efficacy (dependent variable). 

Regression diagnostics were performed to ensure 

assumptions for linear regressions were met. To generate 

the most parsimonious model, analysis was adjusted for 

age, level of amputation, number of comorbidities and 

number of medications. These variables were selected 

based on the literature and their clinical significance.2,28,29  

Due to the small sample size of the current study, no 

subgroup analysis based on level of amputation was 

performed. Significance level was set to p<0.05. Statistical 

analysis was performed using the IBM SPSS Statistics 

version 24.0 (IBM Corporation, Armonk, NY). 

RESULTS 

Demographics are summarized in Table 1. Twenty-seven 

participants were included in the study. Many participants 

(77.8%, n=21) had transtibial amputations; the remainder of 

the participants had transfemoral amputations. Almost 

2/3rds of the study participants were male (63%, n=17). The 

mean balance self-efficacy rating using the ABC scale was 

69.48 ± 14.50, with scores ranging from 35.63 to 89.69.  

Results from objective and subjective measures of walking 

ability are presented in Table 2. After adjusting for 

confounders, single-task and dual-task walking velocity 

along the 6m straight path were both found to be 

independently associated with self-efficacy of balance 

(Table 3). For every 1cm/s increase in walking velocity along 

a 6m path, balance self-efficacy increases by 0.32 for 

single-task (p=0.011) and 0.28 for dual-task conditions 

(p=0.039).  

https://doi.org/10.33137/cpoj.v5i1.36695


 

4 

Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY  

Frengopoulos et al., 2022 CPOJ 

 
Table 1: Demographic and study characteristics of older adults with 
first major, unilateral lower limb amputation at discharge from 
prosthetic rehabilitation. (n=27). 
 

Characteristics Values 

Age (years) 63.6 ± 9.3 

Sex (men) 17 (63.0%) 

Body Mass Index (kg/m2) 27.4 ± 5.4 

Amputation level (n, % transtibial)  21 (77.8%) 

Time between amputation and discharge (days) 142.6 ± 74.6 

Fall in the previous 12 months? (n, % yes) 19 (70.4%) 

Self-reported number of falls 2.1 ± 2.7 

Montreal Cognitive Assessment 25.7 ± 2.9 

Primary Etiology of Amputation (n, %): 

Diabetes Mellitus 17 (63.0%) 

Peripheral Vascular Disease 4 (14.8%) 

Diabetes Mellitus and Peripheral Vascular 
Disease 

1 (3.7%) 

Trauma, Cancer or Other (clotting disorders, 
infection, etc.) 

5 (18.5%) 

Number of medications 10.2 ± 4.6 

Number of comorbidities 5.4 ± 2.2 

Walking aid use at discharge (n, %):  

Single Cane 3 (11.1%) 

Two Canes 3 (11.1%) 

Forearm Crutches 1 (3.7%) 

Standard Walker 1 (3.7%) 

Rollator Walker  19 (70.4%) 
 

Table 2: Results of objective and subjective measures of walking 

ability at discharge from prosthetic rehabilitation. (n=27). 
Abbreviations: PEQ, Prosthesis Evaluation Questionnaire. 

Variables  Mean ± SD 

Objective: 

6m straight path, single task walking velocity (cm/s) 48.98 ± 25.26 

6m straight path, dual task walking velocity (cm/s) 42.54 ± 22.86 

L-Test, single-task walking time (seconds) 79.89 ± 53.01 

L-Test, dual-task walking time (seconds) 97.90 ± 70.40 

Subjective: 

PEQ Ambulation subscale  68.22 ± 19.09 

PEQ 13A: Walking ability w/prosthesis 81.82 ± 16.32 

PEQ 13B: Ability to walk in close spaces w/prosthesis 76.33 ± 24.80 

PEQ 13C: Walk up-stairs w/prosthesis 78.16 ± 20.30 

PEQ 13D:  Walk down stairs w/prosthesis 77.72 ± 21.48 

PEQ 14E: Walk up hill w/prosthesis 54.76 ± 33.17 

PEQ 14F: Walk down-hill w/prosthesis 53.71 ± 32.14 

PEQ 14G: Walk sidewalks w/prosthesis 77.83 ± 30.88 

PEQ 14H: Walk on slippery surfaces w/prosthesis 45.43 ± 30.77 

PEQ question 16B - Satisfaction with walking  88.44 ± 11.80 

Single-task performance on the L-Test and satisfaction with 

walking were also independently associated with self-

efficacy of balance (Table 3). For every one second 

decrease in performance on the L-Test balance self-efficacy 

increases by 0.17 (p=0.035), and for every 1-point increase 

in satisfaction with walking self-efficacy increases by 0.60 

(p=0.019). No associations between the other objective or 

subjective measures and balance self-efficacy were found. 

DISCUSSION 

This study is the first to investigate associations between 

subjective and objective measures of walking ability and 

balance self-efficacy in those with LLA at discharge from 

prosthetic rehabilitation. We identified that straight path 

walking velocity under single and dual-task conditions, time 

to complete the single-task L-Test and self-reported 

satisfaction with walking were associated with balance self-

efficacy at discharge from rehabilitation. This indicates that 

performance on both objective and subjective measures of 

walking ability influence the reported balance self-efficacy 

of individuals with LLA at this point in the prosthetic 

rehabilitation process. 

The relationship between self-efficacy and motor learning is 

circular. As individuals gain self-efficacy they create more 

challenging goals; striving for these goals benefits motor 

learning and performance, leading to further goal setting.30 

According to Bandura, the more mastery experiences that 

one has, the higher they perceive their ability;15 this 

perception of one’s capabilities may be more related to 

performance than physical ability itself.14,15 This is an 

important consideration for individuals with LLA, as levels of 

balance self-efficacy tend to be low.12,31 The results from 

the current study highlights the relationship between 

walking ability and self-efficacy of balance at a single point 

in the rehabilitation journey. Further research is needed to 

fully understand the longitudinal relationship between self-

efficacy, goal setting and walking ability for those with LLAs.  

 

Table 3: Results of multivariable linear regression for the association of objective (6m straight path and L-test walking tests) and subjective 

(PEQ) measures of walking ability on self efficacy (Activities-specific Balance Confidence Scale). Abbreviations: β, regression coefficient; CI, 

confidence interval; PEQ, Prosthesis Evaluation Questionnaire. *Adjusted for age, level of amputation, number of comorbidities, number of 

medications.  

Gait Variable Unadjusted β (95% CI) Adjusted β (95% CI)* 

Objective: 

6m straight path:  
Single task walking velocity (cm/s) 
Dual task walking velocity (cm/s) 

 
0.37 (0.19, 0.55), p<0.001 
0.35 (0.13, 0.57), p=0.003 

 
0.32 (0.08, 0.56), p=0.011 
0.28 (0.02, 0.54), p=0.039 

L-Test: 
Single-task walking time (seconds) 
Dual-task walking time (seconds) 

 
-0.17 (-0.26, -0.09), p<0.001 
-0.11 (-0.18, -0.04) p=0.005  

 
-0.17 (-0.33, -0.01), p=0.035 
-0.08 (-0.20, 0.04), p=0.164 

Subjective:  

PEQ Ambulation Subscale Total Score 0.35 (0.07, 0.63), p=0.016 0.22 (-0.08, 0.52), p=0.140 

PEQ 16B: Satisfaction with walking 0.80 (0.41, 1.18), p<0.001 0.60 (0.11, 1.08), p=0.019 

 

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5 

Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY  

Frengopoulos et al., 2022 CPOJ 

 
The 6m walk was the simplest measure performed by 

participants. In contrast, the L-Test is more complex as it 

incorporates transfers and turning,22 and dual-task testing 

provides an additional cognitive challenge to mimic real-

world multi-tasking.27 As individuals progress through 

prosthetic rehabilitation, they gain self-efficacy through 

mastery of simple tasks, external coaching from expert 

clinicians and vicarious experiences of observing fellow 

patients.13-15 Confidence in performing more complex tasks 

develops later.15 The dual-task L-test is the most complex 

task that individuals were asked to perform in the current 

study. Therefore, it is possible that participants have not yet 

developed balance self-efficacy relating to this task. It is 

expected that individuals will continue to develop self-

efficacy of balance through mastery experiences of more 

difficult walking tasks as they begin to ambulate in the 

community.5 As self-efficacy is activity specific, a task-

specific intervention to improve self-efficacy may be a new 

target for interventions to improve walking ability for those 

with LLA. Task-oriented balance and walking interventions 

have been demonstrated to improve self-efficacy for 

individuals following a stroke.32 

Predictors of walking ability following LLA have been widely 

described in the literature.2,33 Previously identified factors 

tend to refer to physical or objective findings such as level 

of amputation, age, physical fitness and etiology of 

amputation,2,33 and have not included the influence of 

psychological factors. However, Hamamura et al.34 did 

identify motivation to walk as a predictive factor for 

prosthetic rehabilitation in older adults with LLA. Previous 

research has also highlighted that while objective measures 

of walking ability improve following discharge from 

rehabilitation, subjective measures of walking ability do 

not.31 Self-efficacy and motivation, along with other 

psychological factors, may help to explain why subjective 

measures of walking ability do not improve. The current 

study adds to the literature and highlights the relationship 

between the psychological factor of balance self-efficacy 

and walking ability for those with LLA. More research on the 

relationship between psychological factors and their effects 

on subjective measures of walking ability is needed.  

Study Limitations 

These results represent individuals with unilateral LLA at 

discharge from inpatient rehabilitation. More time with a 

prosthesis may impact self-efficacy of balance and the 

relationships described. The individuals in this study were 

>50 years of age, so results may not be relevant for younger 

cohorts or those with fewer comorbidities.  

Transtibial and transfemoral levels of amputation were both 

represented in the current study, however no subgroup 

analysis based on level of amputation was performed due 

to small sample size. Also, for those with transfemoral 

amputations, the type of knee componentry was not 

recorded. Therefore, the current study is not able to 

comment on the impact of level of amputation or prosthetic 

components on the relationship between balance self-

efficacy and walking ability. Analysis based on level of 

amputation should be considered for further studies. 

Also, the objective walking measures used in the current 

study only examine short walking distances. Therefore, the 

association between objective measures of walking ability 

and balance self-efficacy cannot be generalized to longer 

walking measures or measures of endurance. Finally, the 

current study has a small sample size, which may be 

underpowered to detect the changes in all variables 

measured. In future, larger sample sizes should be used to 

confirm the results.   

CONCLUSION 

This study demonstrates the interplay between physical and 

psychological factors during rehabilitation for LLA. Straight-

path walking velocity under single and dual-task conditions, 

performance on the L-Test and self-reported satisfaction 

with walking are independently associated with self-efficacy 

of balance. However, the complex task of completing the 

dual-task L-Test was not found to be associated. Further 

research regarding other factors that may be associated 

with or influence self-efficacy is needed in the LLA 

population.  

ACKNOWLEDGEMENTS 

The authors would like to extend a thank you to all those who 

participated in this study. We sincerely appreciate your time and 

contribution to helping advance rehabilitation for this population. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors have nothing to disclose. 

AUTHOR CONTRIBUTION 

Each author has made an equal contribution to the manuscript in 

the following areas: (1) concept or design of the work, or 

acquisition, analysis or interpretation of data; (2) drafted or critically 

revised the article; (3) approved the version to be published; (4) 

participated sufficiently to take public responsibility for appropriate 

portions of the content. 

SOURCES OF SUPPORT 

This work was supported by the St. Joseph’s Healthcare 

Foundation Cognitive Vitality and Brain Health Seed Funding 

Opportunity in London, Ontario, Canada. The funding body had no 

involvement in the conduct of the study. 

ETHICAL APPROVAL 

The study was approved by the University of Western Ontario 

Ethics Board, and by the Lawson Health Research Institute Clinical 

https://doi.org/10.33137/cpoj.v5i1.36695


 

6 

Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
ASSOCIATION BETWEEN BALANCE SELF-EFFICACY AND WALKING ABILITY  

Frengopoulos et al., 2022 CPOJ 

 
Resources Impact Committee. All individuals provided written 

informed consent prior to participating in the study. 

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Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. 
Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 

ISSN: 2561-987X 
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