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VOLUME 8, ISSUE 1 

 2025 
 

RESEARCH ARTICLE 

 

Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics 

Journal. 2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517  

 

  

 

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1 

Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

 

 

RESEARCH ARTICLE 

 

EXPLORING THE CORRELATION BETWEEN GAIT SPEED AND BALANCE IN LIMB 

PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A1,2, Fiedler G2*  

1. Department of Physical Therapy, Majmaah University, Saudi Arabia. 
2. Department of Rehabilitation Science and Technology, University of Pittsburgh, USA. 
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

INTRODUCTION   

It is estimated that 185,000 individuals in the U.S. undergo 

amputation each year, with the majority of cases attributed 

to diabetes and peripheral vascular disease.1,2 Limb loss 

can also result from traumatic injuries, including motor 

vehicle accidents, combat injuries, and work-related 

accidents.3,4 The removal of cancerous tissues or the 

treatment of certain congenital deformities may result in 

amputation as well.5,6 

As an irreversible impairment of the patient’s physical 

integrity, limb loss poses numerous challenges to activities  

 

of daily living, including participation in society and gainful 

employment. Postural control, for example, is a critical skill 

for sustaining everyday activities. Balance is the capacity to 

realign the center of mass within its base of support to 

maintain stability. Horak7 proposed that maintaining 

postural balance depends on six key sub-components: 

biomechanical constraints, movement strategies, sensory 

strategies, spatial orientation, dynamic control, and 

cognitive processing. Losing a limb alters both the weight 

distribution within the body and the individual’s capacity to 

maintain equilibrium by adjusting body movement.7,8 

In addition, there may be limb-loss related comorbidities 

that increase a patient’s fall risk. Lower limb amputation 

surgery and subsequently reduced mobility are associated 

with high levels of mortality9 and morbidity rates, including 

a higher risk of developing coronary artery disease10 and 

elevated risk of psychiatric disorders.11 Individuals with limb 

loss may have limited walking ability, which is known to 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Increasing balance and stability, along with efficient locomotion, is a high-priority goal of physical 

rehabilitation after limb loss in order to facilitate effective participation in society. Research in the general population 

suggests that the ability to walk fast is correlated to good performance in balance tests. However, it is unclear if 

and how prosthesis use influences this correlation.  

OBJECTIVE: Our small-sample pilot study aimed to explore whether the general relationship between walking 

speed and balance holds true for people with limb loss whose physical capabilities are inevitably influenced by 

their prosthetic devices. 

METHODOLOGY: Participants with any level of limb loss were recruited and asked to perform the Ten-Meter Walk 

Test and Narrowing Beam Walking Test. Scores in both tests were analyzed using Spearman’s rank correlation 

coefficient. 

FINDINGS: The initial sample of eleven participants was reduced to eight (5 males, 3 females, mean age 52 years, 

mean height 171 cm, mean weight 68 kg, mean BMI 23, limb loss levels ranging from partial hand to trans-femoral 

amputation) after removing outliers. The mean Ten-Meter Walking velocity was 1.16 m/s, and the mean Narrowing 

Beam Test score was 11.38. The results indicate a medium to strong correlation between fast walking speed and 

high balance scores (ρ = 0.681, p = 0.063) when outliers are excluded. 

CONCLUSION: These findings are consistent with prior research conducted in other populations. However, 

outliers in our data suggest that this relationship is not universal across all individuals with limb loss. Possible 

confounding variables include the activity level and the respectively prescribed prosthetic technology. Our finding, 

that gait speed and balance scores should be evaluated separately to tailor rehabilitation strategies effectively, is 

preliminary and needs to be confirmed in a larger study. 

 

 

ARTICLE INFO 

Received: May 29, 2025 

Accepted: August 14, 2025 

Published: August 21, 2025 
 

CITATION 

Alhuzaymi A, Fiedler G. 

Exploring the correlation 

between gait speed and 

balance in limb prosthesis 

users: A pilot study. 

Canadian Prosthetics & 

Orthotics Journal. 2025; 

Volume 8, Issue 1, No. 8. 

DOI:10.33137/cpoj.v8i1.45

517 

KEYWORDS 

Limb Loss; Artificial Limbs; 

Gait speed; Balance; Fall 

Risk; Rehabilitation; 

Amputation; Prosthesis; 

Velocity.  

* CORRESPONDING AUTHOR: 
Goeran Fiedler, PhD  

Affiliation: Department of Rehabilitation Science and Technology, 
University of Pittsburgh, USA. 

E-Mail: gfiedler@pitt.edu 

ORCID ID: https://orcid.org/0000-0003-1532-1248 

 

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

Volume 8, Issue 1, Article No. 8. 2025 

 

 

https://doi.org/10.33137/cpoj.v8i1.45517
https://doi.org/10.33137/cpoj.v8i1.45517
https://doi.org/10.33137/cpoj.v8i1.45517
https://orcid.org/0000-0003-1532-1248
https://jps.library.utoronto.ca/index.php/cpoj/index


 

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Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X GAIT SPEED AND BALANCE IN PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A and Fiedler G, 2025 

correlate with poor balance and may restrict activity and 

participation.12 A low activity level has been shown to be 

associated with muscle weakness and impaired joint 

proprioception.13 Gait biomechanics are influenced by both 

reduced walking speeds and lower levels of physical 

activity.14,15 

Post-surgical muscle weakness, after lower or upper limb 

amputation, may further increase fall risk,2 as may side 

effects from prescription medication. This often compounds 

the elevated fall risk that is already typical for old age 

regardless of limb loss status.4 Among the elderly, fear of 

falling has been reported in between 20% to 46% of non-

fallers and 40% to 73% among those who have recently 

fallen.16-20 By comparison, more than half of individuals with 

lower limb loss report a minimum of one fall within a year, 

with roughly about 33% experiencing multiple falls even 

after completing a comprehensive rehabilitation 

program.3,21 

The research literature demonstrates that walking 

performance is directly linked with balance.22-27 Slow gait 

speed is recognized as a significant contributor to fall risk, 

highlighting the need to prioritize the assessment of gait 

speed in people with limb loss to establish comprehensive 

data on fall risk factors.28,29 Most research has focused on 

persons with lower limb loss who have been found to have 

significantly reduced both gait and cognitive performance 

during single-task testing and even more so during dual-

task testing.30 Relatively little is known on how upper limb 

loss affects the relationship between gait speed and 

balance. Furthermore, it is possible that differences in 

prosthetic hardware affect this relationship. For instance, 

prosthetic foot/ankle component designs strike a 

compromise between dynamic efficiency (i.e., gait speed) 

and static stability (i.e., balance) but cannot be optimized for 

both at the same time. This raises the question of whether 

gait speed is as much a generalizable predictor of balance 

(or vice versa) in people with limb loss as it is in the general 

population. 

Despite growing awareness of fall risk factors and 

implementation of prevention strategies, there remains 

room for improvement in fall prevention programs and their 

application in the limb loss population.21 Assessments of the 

risk of falls include both subjective and objective measures. 

Common clinical outcome measures include the Activities-

specific Balance Confidence (ABC) scale,31 the Berg 

Balance Scale (BBS),32 and the Narrowing Beam Walking 

Test (NBWT),33 which have all been found valid and reliable 

to identify potential risk of falling in individuals with 

conditions that compromise balance.33-35 

The ABC has been shown to be limited in distinguishing 

between persons with a transtibial and transfemoral 

amputation.35 The BBS has demonstrated a limited capacity 

to assess the varying degrees of fall risk in persons with 

lower limb loss.34 The NBWT has been recently introduced 

as a standardized test designed to assess a wide spectrum 

of balance capabilities. Its unique feature lies in its capacity 

to pose a significant challenge to those with lower limb loss, 

thereby providing an effective evaluation of their balance 

characteristics.33,36,37 While “off-label” uses of the NBWT in 

other populations may be frequently employed, there is 

limited research to support its clinical use in individuals with 

other impairments than lower limb loss.  

This pilot study aimed to explore the nature of the 

relationship between walking speed and balance in 

individuals with both lower and upper limb loss. Considering 

that either limb loss level affects balance, we hypothesized 

that slower gait speed would be associated with lower 

NBWT scores, irrespective of the level of amputation or the 

used prosthetic componentry. 

METHODOLOGY 

A cross-sectional study was conducted to assess the 

relationship between walking speed and balance in 

individuals with limb loss. The study was approved by the 

Institutional Review Board (IRB) of the University of 

Pittsburgh. All participants provided informed written 

consent prior to their involvement in the study. 

Individuals with limb loss were recruited from the 

institution’s patient registry as well as from local prosthetic 

clinics. All participants were screened based on the 

inclusion criteria that required an age of at least 18 years, 

absence of at least one limb, and the ability to ambulate 

independently. The inclusion criteria were kept deliberately 

broad, in accordance with the study’s aim of exploring 

correlations across the target population, irrespective of the 

severity of their limb loss. In this context, a more narrowly 

selected sample would be not only less representative of 

the population but likely also be too similar in performance 

to allow for meaningful analysis. Potential participants were 

excluded if they were unable to speak and understand 

English to follow study instructions, had bilateral lower limb 

loss, significant sensory or motor neuropathy affecting 

ambulation, severe visual impairments (e.g., blindness), or 

any other condition that could affect the validity of the 

walking assessments. 

A target sample size of 10 was informed by the purpose of 

this pilot study to explore whether there may be an unusual 

correlation of gait speed and balance that warrants further 

exploration. While limiting generalizability of findings, 

subjecting only a small sample to the study protocol is 

ethically motivated and is commensurate with prior research 

studies in the field.38 

Given the wide initial inclusion criteria, post-hoc analyses 

were considered in which the most and/or least physically 

active participants would be excluded from analysis, in an 

effort to reduce heterogeneity and focus on the subsample 

most representative of the majority of people with limb loss. 

https://doi.org/10.33137/cpoj.v8i1.45517


 

3 

Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X GAIT SPEED AND BALANCE IN PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A and Fiedler G, 2025 

Sociodemographic data, including age, height, weight, and 

sex, were collected via self-report. Prosthetic-related data 

such as amputation level, amputation etiology, functional 

(K-) levels, and amputation date were obtained prior to the 

performance tasks. Participants were asked to wear their 

daily-use prostheses and to complete a 10-meter walk test 

(10MWT)39 and the NBWT. 

The 10MWT was performed at preferred gait speed and 

repeated three times, with the mean of the three trials 

utilized for scoring purposes. The 10MWT is a common 

assessment tool used to evaluate gait speed that has a test-

retest reliability of 0.97 ICC.40-43 

The NBWT challenges the participants’ balance control by 

reducing step width. With maximum supervision by the 

investigator, the participants were instructed to cross their 

arms and walk along the narrowing beam. The beam is 

divided into four sections of 1.83 m (6 feet) each for a total 

length of 7.32 m, where each section has a different width, 

starting with 18.6 cm, and narrowing down to 8.6 cm, 4.0 

cm, and 2.0 cm respectively. The beam is made of 5.0 cm 

thick boards and is placed on the level floor of the gait lab. 

The test ends after the participant steps off the beam, 

uncrosses their arms, or achieves the full length of the 

beam. The distance traversed on the beam (in feet) is 

recorded as the test score. The mean of three trials per 

participant was used for analysis.36,37 To assure safety, 

participants were closely monitored by study personnel who 

were positioned close enough to provide support in the 

event of critical stumbles during the balance trials. 

Normality of the distribution of measurements was 

evaluated using the Shapiro-Wilk test. Spearman 

correlation coefficients (ρ) were calculated to analyze the 

correlation between the NBWT scores and 10MWT walking 

speeds. Spearman correlation is comparably robust against 

outliers and heavy-tailed distributions44 that are often found 

in small samples like the one in the present study. Cutoff 

levels for deeming correlations weak (ρ = 0.1), moderate  

(ρ = 0.3), or strong (ρ = 0.5) were determined in accordance 

with convention.45 

For all analyses, the significance level was set at  = 0.1. 

The deviation from the more commonly used significance 

criterion of  = 0.05 is justified by the safety-relevant nature 

of the variables at play.46 A type-2 error (which is less likely 

at  = 0.1) would mean missing a clinically significant 

correlation between gait speed and balance performance, 

which could lead to treatment decisions (e.g., prosthetic 

prescriptions) that are less safe by ignoring this relationship. 

Conversely, the consequences of a type-1 error (which is 

less likely at  = 0.05) are less worrisome (e.g., erroneously 

prescribing a safer prosthesis option than needed). 

RESULTS 

A total of 11 participants fit the inclusion criteria and were 

included in the data collection (Table 1).  The data (Figure 1) 

showed a mean 10MWT gait speed of 1.17 m/s (SD = 0.40 

m/s) and a mean NBWT score of 12.55 (SD = 6.00) across 

the sample. The correlation between those variables was 

weak (ρ = 0.259) and not statistically significant (p = 0.442).  

For a secondary analysis, data were excluded from 

participants who were deemed outliers unrepresentative of 

the general amputee population due to their activity level 

being uncommonly high (along with an unusual amputation 

level, i.e., a Van Ness Rotationplasty, n = 1) or low (signified 

by an age of above 70 years, n = 2).  In the thus updated 

sample (n = 8, Table 1) the mean 10MWT gait speed was 

1.16 m/s (SD = 0.40 m/s) and mean NBWT scores were 

11.38 (SD = 5.76). Their correlation was classified as 

moderate to strong (ρ = 0.681) and was significant at the 

0.1 level (p = 0.063). 

Table 1: Baseline characteristics of participants. 

Variable                 
Mean (Standard Deviation) or Count 

Full sample Sample with outliers removed 

Age (years)       50 (19.4) 52 (17.4) 

Height (cm)              171 (8.01) 171 (8.3) 

Weight (kg)             75 (4.48) 68 (8.3) 

Male/female ratio 8 / 3 (73% / 27%) 5 / 3 (63% / 37%) 

BMIa 25 (1.15) 23 (2.8) 

Amputation type (No.)b    TF (1), TT (4), RP (1), TR (2), TH (2), FA (1) TF (1), TT (4), TR (1), TH (1), FA (1) 

Years since limb loss    19 (17.02) 21 (12.5) 

MFCL (K-) level, (No.)c K1 (0), K2 (0), K3 (9), K4 (2) K1 (0), K2 (0), K3 (7), K4 (1) 

 

a. BMI indicates body mass index, calculated as weight in kilograms divided by height in meters squared. b. Amputation types: TF, transfemoral; TT, transtibial; 

RP, rotationplasty; TR, transradial; TH, transhumeral; FA, finger amputation. c. MFCL indicates Medicare Functional Classification Level; K-levels range from K1 

to K4. 

 

 

https://doi.org/10.33137/cpoj.v8i1.45517


 

4 

Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X GAIT SPEED AND BALANCE IN PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A and Fiedler G, 2025 

 

Figure 1: Scatter plot of 10MWT velocities (in meters per second) 

against NBWT scores (distance covered in feet). Correlations are 

shown for the full sample (continuous blue line) and the modified 

sample without outliers (dashed line). Outliers are circled. 

 

DISCUSSION 

This work explored the hypothesis that the correlation 

between gait speed and balance applies to people with limb 

loss. Participants performed the 10MWT and the NBWT to 

generate the necessary data. Our findings suggest that, by 

trend, participants who took longer to walk 10 meters 

performed worse in the NBWT, which indicates poorer 

balance.  

This does align with previous research that has 

demonstrated the predictive value of gait speed on fall risk 

in various populations, albeit using different assessment 

methods.47-49 This is the first research study that directly 

correlated walking speed and NBWT scores in people with 

limb loss. The strength of the observed correlation was 

limited by the heterogeneity of our full sample, which hints 

at the more complex relationship between gait speed and 

balance in users of limb prostheses. One possible factor 

contributing to this complexity is that the physical 

performance of people with limb loss largely depends on the 

prostheses they use, unlike in able-bodied individuals. It is 

conceivable that, in the case of upper limb loss, the reduced 

weight of the prosthesis (if one is used at all) compared to 

the lost arm may pose no disadvantage when it comes to 

gait speed but could affect the effective response to 

perturbations of the user’s balance. In lower limb 

prosthetics, gait speed and balance are influenced by 

prosthetic design, fit, and alignment. These factors interact 

differently under varying surface conditions, affecting 

overall stability.50-52 

While analyzing these possible relationships was not within 

the scope of the pilot data collection, our data may serve as 

the motivation to further explore them in subsequent work. 

The outliers in our sample may be explained accordingly. 

Two of our participants combined slow walking speed with 

relatively high balance scores, while one showed the 

opposite performance of walking fast but having poor 

balance. It is possible that their prosthetic design was 

optimized for balance at the expense of gait speed (or vice 

versa). While this may have been clinically indicated in 

these individual cases, we argue that the found 

compromises may not have been ideal in that they 

sacrificed one performance measure to benefit another. 

After excluding the outliers, the correlation between speed 

and balance increased in strength and was determined to 

be statistically significant. 

There are other independent variables that are likely to have 

an effect on balance and gait speed, such as the 

participants’ age, cause of limb loss, prosthesis experience, 

and gender. These could be meaningfully investigated in a 

larger scale study where the sample size does not prohibit 

statistical corrections for multiple comparisons. An ad-hoc 

analysis of our sample showed a trend toward better 

balance relative to gait speed in individuals with upper limb 

loss when compared to those with lower limb loss, as 

indicated by a lower Speed/Balance Ratio. However, the 

difference was not statistically significant (p = 0.196, 

Cohen’s d = 0.45), leaving it unresolved whether amputation 

level (upper or lower limb) influences balance relative to gait 

speed. 

The clinical relevance of our findings lies in the expanded 

utility of the NBWT, which may be interpretable beyond its 

intended use as a balance assessment tool. Combining 

speed and balance tests may offer insights into optimization 

potential for prosthesis fitting and/or rehabilitation training.  

Somebody may have “too good” balance, if it comes at the 

expense of walking speed and vice versa. It may be 

interesting to investigate whether completion time of the 

NBWT is a meaningful variable in addition to the distance 

covered. Additionally, longitudinal studies could provide 

insight into whether changes in walking speed over time 

predict corresponding changes in NBWT performance, 

promising a deeper understanding of the dynamic interplay 

between mobility and balance. 

Limitations of this study include the small sample size, 

especially after outliers were removed. The small sample, 

though typical for pilot prosthetics research,53 limits 

generalizability. A larger sample would allow to further 

explore the relationship between gait speed and balance in 

prosthesis users while also considering additional factors 

such as prosthetic prescription, fitness level, and 

neurological conditions that may influence walking speed 

and balance. Including upper and lower limb prosthesis 

https://doi.org/10.33137/cpoj.v8i1.45517


 

5 

Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X GAIT SPEED AND BALANCE IN PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A and Fiedler G, 2025 

users and one participant with multiple finger amputations, 

increased sample heterogeneity. The finger amputation 

may have proprioceptive balance effects, but results may 

differ substantially from participants with major limb loss. 

Future, larger-scale, studies should analyze amputation 

types separately, as well as different types of prosthetic 

hardware. There is a possible training effect that influences 

NBWT scores and that could not be controlled in our 

protocol.  

CONCLUSION 

In people who use limb prostheses, it cannot be assumed 

that there is a universal correlation between gait speed and 

balance. At least in some individuals, slow walking speed is 

not indicative of poor balance or vice versa. To ensure valid 

outcome assessments in clinical care, the two variables 

should be monitored separately. 

ACKNOWLEDGEMENTS 

The authors thank Daniel Rusnak and Bob Maguire for their help in 

protocol design and subject recruitment. The authors also thank all 

participants for their time and valuable contributions to this study.  

DECLARATION OF CONFLICTING INTERESTS 

The authors declare no conflicts of interest.   
 

AUTHORS’ CONTRIBUTION 

• Dr. Abdullah Alhuzaymi: Conceptualization, Methodology, 

Formal analysis, Investigation, Data curation, Writing—original 

draft preparation, Visualization, Funding acquisition.  

• Dr. Goeran Fiedler: Conceptualization, Resources, Writing—

review and editing, Visualization, supervision, Project 

administration, Funding acquisition. 
 

Both authors have read and agreed to the published version of 

the manuscript. 

 

SOURCES OF SUPPORT 

Internal support through the institution. This research received no 

external funding. 

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https://pubmed.ncbi.nlm.nih.gov/9866429/


 

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Alhuzaymi A, Fiedler G. Exploring the correlation between gait speed and balance in limb prosthesis users: A pilot study. Canadian Prosthetics & Orthotics Journal. 
2025; Volume 8, Issue 1, No. 8. DOI:10.33137/cpoj.v8i1.45517 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X GAIT SPEED AND BALANCE IN PROSTHESIS USERS: A PILOT STUDY 

Alhuzaymi A and Fiedler G, 2025 

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CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

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