Four Square Step Test

Last Updated

February 01, 2021

Purpose

A test of dynamic balance and coordination that clinically assesses the participant’s ability to step over objects forward, sideways, and backwards.

Link to Instrument

Instrument Details

Acronym FSST

Area of Assessment

Activities of Daily Living
Balance – Vestibular
Balance – Non-vestibular
Coordination

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Vestibular Disorders

Healthy Adults

Neurological Disorders

Vestibular Disorders

Stroke

Pediatric Disorders

Parkinson's Disease

Older Adults and Geriatric Care

Multiple Sclerosis

Limb Loss and Amputation

Cerebral Palsy

Test may be demonstrated by administrator and one practice trial allowed to ensure understanding
Two trials are performed, and the better time (in seconds) is taken as the score.
Participant steps over four canes that are placed in a ‘plus’ sign arrangement
Instruction: “Complete the test as quickly as possible. Both feet must touch the floor in every square. Try to remain facing forward for the entire test and do not touch the canes as you step from square to square."
Participant begins test by standing in Square 1 facing Square 2. Square 4 is to the right of Square 1
Stopwatch should start when the first foot makes contact with square 2 and stops when the last foot makes contact with the square 1.
Stepping Sequence with both feet touching each square:
- Clockwise: Square 1, Square 2, Square 3, Square 4, Square 1
- Counter-clockwise: Back to Square 4, Square 3, Square 2, Square 1
Can be completed on a foam surface

Number of Items

Stopwatch
Four canes

Less than 5 minutes

Required Training

No Training

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

(2020) Updated By: Taylor Geringer, SPT and Jana Schammel, SPT; Faculty Advisors: Kathleen Luedtke-Hoffmann, PT, PhD; Kenneth Miller, PT, DPT, MA University of North Texas Health Science Center

Reviewed By Shirley Ryan AbilityLab RMD Team: Rudy Chiu, MS and Dhrumil Shah, MPH

(2013) Initially reviewed by the Rehabilitation Measures Team; Updated by Katie Hays, PT, DPT and the TBI EDGE task force of the Neurology Section of the APTA. Updated by Linda B. Horn, PT DScPT, MHS,NCS, Karen H. Lambert PT, MPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Scelerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PDEDGE), Spinal Cord Injury Taskforce (SCI EDGE), Stroke Taskforce (StrokEdge), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE). These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
LS / UR	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks

Vestibular EDGE

N/A

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

	I	II	III	IV	V
PD EDGE	LS/UR	R	R	R	NR

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

Completely Independent

Mildly

Dependent

Moderately Dependent

Severely Dependent

TBI EDGE

Recommendations based on EDSS Classification:

	EDSS 0.0 – 3.5	EDSS 4.0 – 5.5	EDSS 6.0 – 7.5	EDSS 8.0 – 9.5
MS EDGE	UR	R	R	NR

Recommendations based on vestibular diagnosis

Peripheral

Central

Benign Paroxysmal

Positional Vertigo (BPPV)

Other

Vestibular EDGE

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
MS EDGE	No	Yes	No	No
PD EDGE	No	No	Yes	Not reported
TBI EDGE	No	No	No	Not reported
Vestibular EDGE	Yes	Yes	Yes	Yes

Considerations

Participants may be given a demonstration and one practice trial prior to their timed attempts.

Participants may need rest breaks between trials to avoid fatigue.

40-62% of participants had unsuccessful trials at least once during testing, Participants found the test more difficult to perform than the Step Test. However, FSST was preferred by participants because they felt it was relevant to daily life and examined challenging skills (Blennerhassett and Jayalath, 2008).

The Four Square Step Test may be helpful in identifying individuals (older adults > 65 y/o) with vestibular disorders who have difficulty changing directions (Whitney 2007).

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Standard Error of Measurement (SEM)

Older Adults with Hip Osteoarthritis: (Choi et al., 2014, n=30; mean age = 63.3 (5.71) years)

SEM for between raters at session 1 (n =30): 0.77
SEM for within rater 1 at 1 week follow-up (n=27): 0.86
FSST had sufficiently low error of measurement (<10%) for both test situations

Minimal Detectable Change (MDC)

Older Adults with Hip Osteoarthritis: (Choi et al., 2014)

MDC90 for between raters at session 1 (n = 30): 1.8
MDC90 for within rater 1 at 1 week follow-up (n = 27): 2.00

Cut-Off Scores

Older Adults/Geriatric: (Dite & Temple, 2002; n = 81 community dwelling adults > 65 years old)

> 15 second = at risk for multiple falls

Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=54)

Cut-off score in order to discriminate between a faller and non-faller was 10.14 seconds with a specificity= 0.667 and sensitivity= 0.667

	Cut-off score	Sensitivity	Specificty
FSST performed on foam surface	11.21	0.889	0.611
FSST performed on hard surface	10.14	0.667	0.725

Cutoff Score, Sensitivity, Specificity, AUC, LR+, and LR− of FSST, and FSST + foam for Discriminating Between Nonfaller Older Adults and Adults

	Cut-off score	Sensitivity	Specificty
FSST performed on foam surface	8.16	1.00	0.94
FSST performed on hard surface	7.42	0.89	0.89

Older Adults: (Clearly and Skornyakov, 2017)

Cut-off score of the FSST to discriminate between multiple fallers and non-multiple fallers was 15 seconds (p=0.02)

Older Adults: (Dawson et al., 2018)

A cut-off score of 15 seconds serves as threshold of older adults at risk for multiple falls; specificity=88%, sensitivity=85%

Normative Data

Older Adults/ Geriatric: (Dite et al, 2007)

Balance and Mobility Assessments between groups
Assessments	Multiple Fallers	Non-multiple Fallers
FSST (s)	32.6 (10.1)	17.6 (8.3)
TUG test (s)	25.0 (6.9)	16.2 (5.3)
Turn time (s)	5.2 (1.6)	3.1 (1.0)
Turn steps (n)	5.2 (1.2)	6.8 (1.2)
LCI advanced (score)	12.9 (4.3)	17.6 (4.2)
mean (SD)

Non-Faller Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

11.03 seconds (IQR=9.08-12.36) for FSST+foam
9.80 seconds (IQR=7.82-10.41) for FSST without foam

Faller Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

12.25 seconds (IQR=11.30-26.08) for FSST+foam
10.63 seconds (IQR=9.16-19.37) for FSST without foam

Older Adults: (Cleary and Skornyakov, 2017)

14.2 seconds (±1.3) for non-fallers (n=22)
12.0 seconds (±2.0) for single-fallers (n=4)
22.8 seconds (±4.7) for multiple-fallers (n=7)

Older Adults with Hip Osteoarthritis: (Choi et al, 2014)

Entire group (n = 30):
- Rater A: 8.97 (2.32) seconds
- Rater B: 8.56 (2.01) seconds
Follow-up group (n = 27):
- Session 1: 9.07 (2.35) seconds
- Session 2 (~1 week later): 8.31 (2.45)

Hip Osteoarthritis: (Batting and Barker, 2019, n=58; mean age=70.6 (7.1) years old, 55% female, recruited from specialist orthopaedic hospital)

First assessment mean: 13.7 (5.6) seconds
Second assessment:
- Rater A: 14.2(6.5) seconds
- Rater B: 13.6(5.6) seconds
Follow-up assessment:
- Time 1: 11.1 (3.2) seconds
- Time 2: 10.8(3.0) seconds

Healthy Older Adults: (Goh et al., 2013, n=15)

FSST Mean Score = 7.49 ± 2.34 seconds

Test/Retest Reliability

Geriatric: (Dite & Temple, 2002)

Excellent test-retest reliability (ICC = 0.98)

Interrater/Intrarater Reliability

Inter-rater Reliability

Geriatric: (Dite & Temple, 2002)

Excellent inter-rater reliability (ICC = 0.99)

Older Adults with Hip Osteoarthritis: (Choi et al., 2018)

Excellent inter-rater reliability in individuals 1-week post (ICC = .86)

Older Adults with Hip Osteoarthritis: (Batting and Barker, 2019)

Before Total Hip Replacement, Inter-rater reliability between two assessors (A vs B) had a mean difference of 0.6 seconds

Intra-rater Reliability

Older Adults with Hip Osteoarthritis: (Choi et al., 2018)

Excellent intra-rater reliability in individuals 1-week post (ICC = .83)

Older Adults with Hip Osteoarthritis: (Batting and Barker, 2019)

Before Total Hip Replacement, Intra-rater reliability with Bland and Altman limits of agreement were 3.5 to -3.2 with mean difference of 0.14 seconds

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Geriatric: (Dite & Temple, 2002)

Excellent concurrent validity with the Step Test (r = -0.83)
Excellent concurrent validity with the Timed Up and Go test (r = 0.88)
Adequate concurrent validity with the Functional Reach Test (r = -0.47)

Hip Osteoarthritis: Batting and Barker, 2019(n=58; mean age=70.6 (7.1) years)

Excellent correlation with the figure of 8 walk test (r = 0.7, p < 0.01)
Excellent correlation with the Berg Balance Scale (r = -0.6, p < 0.01)

Older Adults: (Clearly and Skornyakov, 2017); n = 45; mean age = 84.2 (6.3) years

Instrument	Spearman Rho (p) / Pearson Correlation Coefficient (r)
Berg Balance Scale	ρ = -0.74
Timed Up and Go	r = 0.89
Tinetti balance assessment	ρ = -0.60

Predictive Validity

Older Adults: (Clearly and Skornyakov, 2017)

FSST ability to predict falls at:	R² coefficient
3 months	0.38
6 months	0.37
12 months	0.42

Responsiveness

Geriatric: (Dite & Temple, 2007)

Score Multiple (n = 13) vs Non multiple Fallers (n = 27)
Measures	Cutoff	Sensitivity (%)	Specificity (%)	Positive (%)	Negative (%)
FSST	> 24s	92	93	86	96
TUG test	> 19s	85	74	61	91
Turn time	> 3.7s	85	78	65	91
Turn steps	> 6 steps	100	74	65	100
Turn steadiness	NO	31	85	50	72
LCI advanced	< 15	43	91	75	72

NOTE. Predictive value positive reflects the probability that scoring above the cutoff correctly identified multiple fallers, and predictive value negative reflects the probability that the non- multiple fallers were correctly identified as scoring at or below the cutoff (Dite & Temple, 2002).

Minimal Detectable Change (MDC)

Parkinson’s Disease: (Wagner et al., 2013, n=25, mean age = 41.6 (9.8))

MDC = 4.6 sec

Cut-Off Scores

Parkinson's Disease: (Duncan & Earhart et al, 2013; n = 53; mean age = 70 (7.4) years)

> 9.68 seconds = increased risk for falls

Normative Data

Parkinson's Disease: (Duncan & Earhart et al, 2013)

	On Drug	Off Drug
Mean	9.6	11.02
Range	8.73 - 10.62	9.42 - 12.56

Parkinson’s Disease: (McKee and Kackney, 2014; n=31)

Mean time of Trial 1 = 15.9±5.8 seconds
Mean time of Trial 2 = 14.5±6.7 seconds
Mean time of Trial 3 = 13.0±4.6 seconds
Mean best time = 12.9±4.5 seconds

Test/Retest Reliability

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Excellent reliability on medication (ICC = 0.78)
Excellent reliability off medication (ICC = 0.90)

Parkinson’s Disease: (McKee and Kackney, 2014); n = 31; mean age = 69.65 (7.7) years; UPDRS-III used to determine severity of disease; all participants were on PD medication

Adequate to Excellent test-retest reliability, ICC = 0.55-0.88 between three trials

Interrater/Intrarater Reliability

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Excellent inter rater reliability (ICC = 0.99)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Test	Spearman Correlation
MDS UPDRS Scale III	0.61
Mini Best	-0.65
5 Times to Sit to Stand	0.58
6 Minute Walk Test	-0.52
9 Hole Peg Test	0.65
Freezing of Gait Questionnaire	0.44

(All significant at p < 0.001)

Parkinson’s Disease: (McKee and Kackney, 2014; n=31)

Outcome Measure	Spearman Correlation Coefficient (ρ)
TUG (s)	0.734 (Excellent)
TUG-Cognitive (s)	0.634 (Excellent)
TUG-Manual (s)	0.556 (Adequate)
BBS (/56)	-0.659 (Excellent)
360 Degree Turn Test	0.492 (Adequate)
6MWT (m)	-0.476 (Adequate)
30 Second Chair Stand (s)	-0.475 (Adequate)
Activities Specific Balance Confidence Scale (%)	-0.468 (Adequate)

(For all correlations, p<0.01)

Responsiveness

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Measures	Cut Off	Sensitivity (%)	Specficity (%)	Positive (%)	Negative (%)
FSST	9.68 s	73	57	1.7	0.48

Cut-Off Scores

Acute Stroke: (Blennerhassett and Jaylath, 2008; n = 37; mean age = 53(range 23-75) years, time since stroke = 66 (range 9-1094) months; FIM walking item range 4-7, Australian sample):

Failed attempt or > 15 seconds = increased risk for falls

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years); minimum 6 months post stroke)

Time of 11 seconds was found to differentiate between subjects with chronic stroke and healthy control subjects
Sensitivity (73.3%); Specificity (93.3%); AUC = .867; P ≤ 0.001

Normative Data

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST Normative Data:
	Initial (n = 37)	2 Weeks (n = 28)	4 Weeks (n = 20)
Mean (SD)*	20.8 (15.0)	17.9 (11.6)	17.5 (14.5)
Range*	6.1–60.1	5.8–54.9	5.1–53.3
Participants with unsuccessful trials n (%)	23 (62%)	11 (39%)	8 (40%)
Participants unable to be scored n (%)	5 (14%)	3 (11%)	3 (15%)
*Time in seconds

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years)

Mean time was 17.44±9.12 seconds

Test/Retest Reliability

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST Change Over Time:
	Initial to 2 weeks	2 Weeks to 4 weeks	Initial to 4 Weeks
Participants:	n = 24	n = 17	n = 16
Significance:	p = 0.008	p = 0.01	p = 0.01
Difference	d = 0.26	d = 0.08	d = 0.33
95% CI	0.4 to 5.2	-3.4 to 5.8	-2.0 to 10.7

Chronic Stroke: (Goh et al., 2013)

Excellent test-retest reliability (ICC = 0.93 - 0.98)

Interrater/Intrarater Reliability

Intra-rater Reliability

Chronic Stroke: (Goh et al., 2013)

Excellent intra-rater reliability (ICC = .83)

Interrater Reliability

Chronic Stroke: (Goh et al., 2013)

Excellent interrater reliability (ICC = .99)

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST and Step Test Correlations:
Tests Examined	Initial	2 Weeks	4 Weeks
Step test: right and left stance	0.86*	0.92*	0.96*
FSST and step test right stance	-0.86*	-0.78*	-0.81*
FSST and step test left stance	-0.78*	-0.73*	-0.84*
Spearman rho correlation coefficients *p < 0.01

Construct Validity

Chronic Stroke: (Goh et al., 2013)

Construct Validity Evidence: Pearson correlation coefficients relating FSST times with other measures
Measures	Pearson Correlation Coefficient (r)
BBS	-.28
LOS EPE - Forward	-.58*
LOS EPE - Backward	.34
LOS DC - Forward	.21
LOS DC - Backward	.64
TUG	.59*
*Indicates r value that is close to significance with p≤.02

No statistically significant correlation between FSST and BBS scores.
FSST times show close-to-significant correlation with TUG scores.
Among the LOS data, the observed FSST times correlated significantly only with DC in the backward direction & correlated significantly with EPE in the forward direction

Floor/Ceiling Effects

Stroke: (Blenerhassett and Jayalath, 2008)

Floor effect: 40-62% of participants had unsuccessful trials at least once during testing

Responsiveness

Acute Stroke: (Blenerhassett and Jayalath, 2008, measured over a 4 week period of outpatient rehabilitation)

Moderate Change:
- Baseline to 2 weeks (ES = 0.260)
- Baseline to 4 weeks (ES = 0.33)
Small Change:
- 2 weeks to 4 weeks (ES = 0.08)

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years); minimum 6 months post stroke)

Time of 11 seconds was found to differentiate between subjects with chronic stroke and healthy control subjects
Sensitivity (73.3%); Specificity (93.3%); AUG = .867; P<= .001

Cut-Off Scores

Vestibular: (Whitney et al, 2007; n = 32; mean age = 63.7 (17.8) years)

> 12s = at risks for falls

Test/Retest Reliability

Vestibular Disorders: (Whitney et al, 2007)

Excellent test retest reliability (ICC = 0.93)

Criterion Validity (Predictive/Concurrent)

Vestibular Disorders: (Whitney et al. 2007)

Adequate concurrent validity with the Timed Up and Go test (r = 0.69)
Adequate concurrent validity with Gait Speed (r = 0.65)
Adequate concurrent validity with the Dynamic Gait Index (r = -0.51)
Poor concurrent validity with the Dizziness Handicap Inventory (r = -0.13)
Poor concurrent validity with the Activities-Specific Balance Confidence (r = -0.12)

Cut-Off Scores

Transtibial Amputation: (Dite et al, 2007; n = 40; 13 multiple fallers mean age 65.23 (11.18) years, & 27 non-fallers mean age 59.93 (14.28) years, retest 6 months later)

> 24 seconds = at risk for falls

Standard Error of Measurement (SEM)

Children with Down Syndrome: (Bandong et al., 2015, n=14; mean age = 8.7 (1.9) years)

SEM = 2.32 seconds

Minimal Detectable Change (MDC)

Children with Down Syndrome: (Bandong et al., 2015, n=14)

MDC = 6.43 seconds

Normative Data

Children with Down Syndrome: (Bandong et al., 2015)

Children with DS had a mean score of 21.7 s (SD = 5.1)

Children with Down Syndrome: (Verma et al., 2014, n=13; mean age= 12.76 (2.9) years old)

Mean FSST Score = 8.70 sec

Test/Retest Reliability

Children with Down Syndrome: (Bandong et al., 2015, n=14)

Adequate to Excellent test-retest reliability: (ICC Range = .67 - .81 across Raters 1, 2, and 3)

Children with Down Syndrome: (Verma et al., 2014, n=13; mean age= 12.76 (2.9) years old)

Adequate test-retest reliability (ICC = 0.70)

Interrater/Intrarater Reliability

Inter-rater Reliability

Children with Down Syndrome: (Bandong et al., 2015, n=14)

Adequate inter-rater reliability (ICC = .69)

Children with Down Syndrome: (Verma et al., 2014)

Excellent inter-rater reliability in individuals 7 days post (ICC = 0.78)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Children with Down Syndrome: (Bandong et al., 2015, n=14)

Excellent correlation with Timed Up-and-Go test: ρ = 0.71

Children with Down Syndrome: (Verma et al., 2014)

Adequate negative correlation with fuctional reach test (FST): ρ = -0.58

Standard Error of Measurement (SEM)

Huntington’s Disease: (Kloos et al., 2014, n= 24; mean age 50.9 years old)

SEM = 1.14 seconds

Minimal Detectable Change (MDC)

Huntington’s Disease: (Quinn et al., 2013, n= 75; mean age= 52.12 (11.82) years old)

Diagnosis	MDC
Pre-Manifest Huntington’s Disease (n=11)	1.95 seconds
Manifest Huntington’s Disease (n=59)	15.27 seconds
Early Stage Huntington’s Disease (n=20)	7.94 seconds
Middle Stage Huntington’s Disease (n=18)	22.40 seconds
Late Stage Huntington’s Disease (n=21)	13.02 seconds

Huntington’s Disease: (Kloos et al., 2014, n=19)

MDC = 3.25 seconds

Normative Data

Huntington’s Disease: (Quinn et al., 2013)

Diagnosis	FSST Mean Score in sec (SD)
Pre-Manifest Huntington’s Disease	11.68 (2.36)
Manifest Huntington’s Disease	14.98 (11.19)
Early Stage Huntington’s Disease	12.91 (6.82)
Middle Stage Huntington’s Disease	17.50 (8.71)
Late Stage Huntington’s Disease	14.79 (15.64)

Huntington’s Disease: (Kloos et al., 2014, n=19)

Mean time over two trials = 11.22 seconds

Test/Retest Reliability

Huntington’s Disease: (Quinn et al., 2013)

Diagnosis	FSST: ICC Score
Pre-Manifest Huntington’s Disease	0.91 (Excellent reliability)
Manifest Huntington’s Disease	0.78 (Excellent reliability)
Early Stage Huntington’s Disease	0.74 (Excellent reliability )
Middle Stage Huntington’s Disease	0.53 (Adequate reliability)
Late Stage Huntington’s Disease	0.91 (Excellent reliability)

Huntington's Disease: (Kloos et al., 2014)

Excellent test-retest reliability (ICC = .86)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Huntington’s Disease: (Kloos et al., 2014)

Adequate concurrent validity with the Activities-specific Balance Confidence Scale (ABC Scale) = -0.57
Excellent concurrent validity with the Tinetti Mobility Test = -0.67

Standard Error of Measurement (SEM)

Adults with Cerebral Palsy: (Levin et al., 2019; n=18; mean age = 32.7 (9.3); Level I or II on the GMFCS-E&R with spastic CP)

SEM = 1.35 seconds

Children with Cerebral Palsy: (Bandong et al., 2015, n=16; mean age = 8 (2.4) years; Level I and II on the Gross Motor Function Classification System (GMFCS))

SEM = 1.34 seconds

Minimal Detectable Change (MDC)

Adults with Cerebral Palsy: (Levin et al., 2019, n=18)

MDC = 3.7 seconds

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

MDC = 3.71 seconds

Normative Data

Adults with Cerebral Palsy: (Levin et al., 2019)

Mean score = 14.8±4.7 seconds on Test 1
Mean score = 14.0±4.3 seconds on Test 2

Test/Retest Reliability

Adults with Cerebral Palsy: (Levin et al., 2019)

Excellent test-retest reliability (ICC = .91)

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

Adequate to Excellent test-retest reliability: (ICC Range = .51-.92 across Raters 1, 2, and 3)

Interrater/Intrarater Reliability

Interrater Reliability

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

Excellent inter-rater reliability (ICC = .86)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

Excellent correlation with Timed Up-and-Go test: ρ = 0.70

Standard Error of Measurement (SEM)

Multiple Sclerosis (Wagner et al., 2013, n=25, mean age = 41.6 (9.8))

SEM = 1.67 sec

Normative Data

Multiple Sclerosis: (Kalron & Givon, 2016; n=218)

Population Subgroups	FSST Mean Score in sec (SD)
Entire group (n=218)	11.0±4.9
Very mild disability subgroup (n=67)	8.8±3.4
Mild disability subgroup (n=111)	11.0±4.9
Moderate disability subgroup (n=40)	14.1±5.3
Fallers (n=111)	12.5±5.7
Non-fallers (n=107)	9.0±2.6

Test/Retest Reliability

Multiple Sclerosis (Wagner et al., 2013, n=25)

Excellent test re-test reliability (ICC= 0.922)

Criterion Validity (Predictive/Concurrent)

Multiple Sclerosis (Wagner et al., 2013)

Outcome Measure	Spearman Correlation Coefficient (ρ)
BBS	-0.84	Excellent
DGI	-0.81	Excellent
ABC Scale	-0.78	Excellent

Multiple Sclerosis: (Kalron & Givon, 2016, n=218; mean age = 43.2 (13.5) years old))

Test	Correlation Coefficient with FSST (Pearson’s ρ)
2-minute walk	-.575 (Adequate)
Timed Up and Go	.652 (Excellent)
Timed 25-foot walk	.494 (Adequate)
Multiple Sclerosis Walking Scale (score)	.400 (Adequate)
Modified Fatigue Impact Scale (score)	.210 (Poor)
Falls Efficacy Scale – International (score)	.481 (Adequate)
Expanded Disability Status Scale	.457 (Adequate)

Normative Data

Healthy Adults: (Dawson et al., 2018, n=105; mean age = 24.5 (4.66) years old, 73.3% female, recruited at a university)

Mean score: 6.29 ± 1.13 seconds for first trial, 6.14 ± 1.19 seconds for second trial

Healthy Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

7.37 seconds (IQR=7.10-8.03) for FSST+foam
6.44 seconds (IQR=6-7.28) for FSST without foam

Test/Retest Reliability

Healthy Adults: (Dawson et al., 2018, n=105; mean age = 24.5 (4.66) years old)

Excellent test-retest reliability (ICC = .92)

Construct Validity

Convergent Validity

Healthy Adults: (Dawson et al., 2018)

Poor construct validity
- r = .14 between TUG;
- r = -.15 between Biodex SD LOS,
- r = .14 between Biodex SD m-CTSIB Stability Index;
- r = .21 between Biodex SD m-CTSIB-Condition 1

Bibliography

Bandong, A.N., Madriaga, G.O., & Gorgon, E.J. (2015). Reliability and validity of the Four Square Step Test in children with cerebral palsy and Down syndrome. Research in developmental disabilities, 47, 39–47. Find it on PubMed.

Batting, M., & Barker, K. (2019). Reliability and validity of the Four Square Step Test in patients with hip osteoarthritis before and after total hip replacement. Physiotherapy, 105(2), 244-253. doi:10.1016/j.physio.2018.07.014

Blennerhassett, J. M. and Jayalath, V. M. (2008). "The Four Square Step Test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people poststroke." Arch Phys Med Rehabil 89(11): 2156-2161. Find it on PubMed

Choi, Y.M., Dobson, F., Martin, J., Bennel, K. L., & Hinman, R. S. (2014)). Interrater and intrarater reliability of common clinical standing balance tests for people with hip osteoarthritis. Physical therapy, 94(5), 696-704. Find it on PubMed.

Cleary, K., & Skornyakov, E. (2017). Predicting falls in older adults using the Four Square Step Test. Physiotherapy theory and practice, 33(10), 766-771. Find it on PubMed

Dawson, N., Dzurino, D., Karleskint, M., & Tucker, J. (2018). Examining the reliability, correlation, and validity of commonly used assessment tools to measure balance. Health science reports, 1(12), e98. Find it on PubMed

Dite, W., Connor, H. J., et al. (2007). "Clinical identification of multiple fall risk early after unilateral transtibial amputation." Arch Phys Med Rehabil 88(1): 109-114. Find it on PubMed

Dite, W. and Temple, V. A. (2002). "A clinical test of stepping and change of direction to identify multiple falling older adults." Arch Phys Med Rehabil 83(11): 1566-1571. Find it on PubMed

Duncan, R. P. and Earhart, G. M. (2013). "Four Square Step Test Performance in People With Parkinson Disease." Journal of Neurologic Physical Therapy 37(1): 2-8.

Goh, E. Y., Chua, S. Y., Hong, S. J., & Ng, S. S. (2013). Reliability and concurrent validity of Four Square Step Test scores in subjects with chronic stroke: a pilot study. Archives of physical medicine and Rehabilitation, 94(7), 1306-1311. Find it on PubMed

Kalron, A., & Givon, U. (2016). Construct Validity of the Four Square Step Test in Multiple Sclerosis. Archives of physical medicine and rehabilitation, 97(9), 1496–1501. Find it on PubMed

Kloos, A. D., Fritz, N. E., Kostyk, S. K., Young, G. S., & Kegelmeyer, D. A. (2014). Clinimetric properties of the Tinetti Mobility Test, Four Square Step Test, Activities-specific Balance Confidence Scale, and spatiotemporal gait measures in individuals with Huntington’s Disease. Gait & posture, 40(4), 647-651. Find it on PubMed

Levin, I., Lewek, M. D., Giuliani, G., Faldowski, R., & Thorpe, D. E. (2019). Test-retest reliability and minimal detectable change for measures of balance and gait in adults with cerebral palsy. Gait & posture, 72, 96-101. Find it on PubMed

Mathurapongsakul, P., & Siriphorn. A. (2018). Four Square Step Test with foam is more accurate than those without foam for discriminating between older adults with and without fall history. Journal of aging and physical activity, 26(4), 634-628. Find it on PubMed

Mckee, K. E., & Hackney, M. E. (2014). The Four Square Step Test in individuals with Parkinson’s Disease: association with executive function and comparison with older adults. NeuroRehabilitation, 35(2), 279-289. Find it on PubMed

Quinn L., Khalil, H., Dawes, H., Fritz, N. E., Kegelmeyer, D., Kloos, A. D., Gillard, J. W., Busse, M, & Outcome Measures Subgroups of the European Huntington’s Disease Network (2013). Reliability and minimal detectable change of physical performance measures in individuals with pre-manifest and manifest Huntington’s Disease. Physical therapy, 93(7), 942-956. Find it on PubMed

Verma, A., Samuel, A. J., & Aranha, V. P. (2014). The Four Square Step Test in children with Down Syndrome: reliability and concurrent validity. Journal of pediatric neurosciences, 9(3), 221-226. Find it on PubMed

Whitney, S. L., Marchetti, G. F., et al. (2007). "The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder." Arch Phys Med Rehabil 88(1): 99-104. Find it on PubMed

Wagner JM, Norris RA, Van Dillen LR, Thomas FP, Naismith RT. Four Square Step Test in ambulant persons with multiple sclerosis: validity, reliability, and responsiveness. Int J Rehabil Res. 2013;36(3):253-259. Find it on PubMed

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Atomized Content

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Cut-Off Scores

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Responsiveness

Minimal Detectable Change (MDC)

Cut-Off Scores

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Responsiveness

Cut-Off Scores

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Construct Validity

Floor/Ceiling Effects

Responsiveness

Cut-Off Scores

Test/Retest Reliability

Criterion Validity (Predictive/Concurrent)

Cut-Off Scores

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Normative Data

Test/Retest Reliability

Criterion Validity (Predictive/Concurrent)

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Standard Error of Measurement (SEM)

Normative Data

Test/Retest Reliability

Criterion Validity (Predictive/Concurrent)

Normative Data

Test/Retest Reliability

Construct Validity

Bibliography

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