Skip to main content
  

Rehab Measures: Four Step Square Test

Link to instrument

Four Step Square Test Instructions 

Title of Assessment

Four Step Square Test 

Acronym

FSST

Instrument Reviewer(s)

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. Updayed 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

Summary Date

6/16/2013 

Purpose

Test of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backwards

Description

  • Test procedure may be demonstrated and one practice trial is allowed prior to administering the test
  • Two trials are then performed, and the better time (in seconds) is taken as the score
  • Timing starts when the right foot contacts the floor in square 
  • Instructions:

“Try to complete the sequence as fast as possible without touching the sticks. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.”

  • Repeat a trial if the patient:
    • Fails to complete the sequence successfully
    • Loses balance
    • Makes contact with the cane
  • Patient steps over four canes set-up like a cross on the floor with the tips of the canes facing together.
  • At the start of the test, the patient stands on the upper left square (in Square 1, facing Square 2).
    • The stepping sequence is (clockwise):
      • Square 1, Square 2, Square 4, Square 3, return to Square 1 with both feet
    • Then (counterclockwise):
      • Back to Square 3, Square 4, Square 2, and end in Square 1 with both feet.

*Patients who are unable to face forward during the entire sequence and may turn before stepping into the next square and are timed accordingly

Area of Assessment

Activities of Daily Living; Balance Vestibular; Balance Non-Vestibular 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

ADL; Motor 

Assessment Type

Observer 

Length of Test

05 Minutes or Less 

Time to Administer

<5 minutes

Number of Items

Not applicable  

Equipment Required

  • Stopwatch
  • Four canes

 

Training Required

None necessary

Type of training required

No Training 

Cost

Free 

Actual Cost

Free

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Geriatrics; Lower Limb Amputation; Vestibular Disorders 

Populations Tested

  • Geriatric 
  • Parkinson's Disease
  • Stroke
  • Transtibial amputation
  • Vestibular disorders

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Older Adults/ Geriatric:
(Dite & Temple, 2002; n = 81 community dwelling adults > 65 years old)
  • > 15 second = at risk for multiple falls

Vestibular:

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

  • > 12s = at risks for falls

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

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

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

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
 
Older Adults/ Geriatric:
(Dite & Temple, 2002)
 
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)
 
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

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

 
Geriatric:
(Dite & Temple, 2002)
  • Excellent test-retest reliability (ICC = 0.98)

Vestibular Disorders:

(Whitney et al, 2007)

  • Excellent test retest reliability (ICC = 0.93)

Parkinson's Disease:

(Duncan & Earhart et al, 2013)

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

Interrater/Intrarater Reliability

Geriatric:
(Dite & Temple, 2002)
  • Excellent inter-rater reliability (ICC = 0.99)

Parkinson's Disease:

(Duncan & Earhart et al, 2013)

  • Excellent inter rater reliability (ICC = 0.99)

Internal Consistency

Not applicable

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

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)
  • Fair concurrent validity with the Functional Reach Test (r = -0.47)

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)

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)

Construct Validity (Convergent/Discriminant)

Not Established

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Stroke:

(Blenerhassett and Jayalath, 2008)

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

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).

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)

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

Professional Association Recommendations

Recommendations from the Neurology Section of the American Physical Therapy Association’s StrokEDGE Taskforce, MSEDGE Taskforce, SCI EDGE Taskforce, and the TBI EDGE Taskforce are listed below. 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 based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

R

UR

R

UR

TBI EDGE

NR

LS

LS

LS

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

LS

LS

LS

NR

 

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 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)

Is this tool appropriate for use in intervention research studies? (Y/N)

MS EDGE

No

Yes

No

TBI EDGE

No

No

No

Considerations

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).
 
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

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 

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.

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

Year published

2002 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 1/31/2014 2:17 PM  by Jason Raad